EMR Pearls and Perils

Documentation Uses Historical record of what took place during a provider patient encounter Allows for efficient communication between healthcare providers for continuity of care Additional uses Data Collection for research and education Utilization management Quality Claims adjudication Selection Considerations Physician involvement Research Test drive Interviews Current long term user New user Financing 2

Which EMR is Best for Your Practice? Certified players Well known Lesser known Flexibility Support Upgrades Legal review Implementation Privacy and security Meaningful Use American Recovery and Reinvestment Act of 2009 specifies three main components: 1.The use of a certified EHR in a meaningful manner, such as e-prescribing 2.The use of certified EHR technology for electronic exchange of health information to improve quality of health care 3.The use of certified EHR technology to submit clinical quality and other measures Source: CMS EHR Meaningful Use Overview 3

Certification Meaningful use Need to demonstrate that provider is using certified EHR technology in ways that can be measured significantly in quality and quantity Certified EHR technology Even if already using EHR technology, it must be tested and certified by an Office of the National Coordinator Authorized Testing and Certification Body (ONC-ATCB) specifically for the Medicare and Medicaid EHR Incentive Programs Certification by ONC-ATCB is not an endorsement by HHS or guarantee for receipt of incentive payments Source: CMS Certified EHR Technology Nonproprietary Open Source EMR Benefits Source code available for customizing Upgrades Low cost Barriers Level of support Implementation Dependability that open source vendor will be in business in 5 years 4

EMR Flexibility Practice specific program? One size only? Will it grow with my practice? User friendly? User defined parameters? Old data? Outside documents? Lab/Radiology/Consults Other EMR platforms Facsimiles Free text usage? Support Level of vendor assistance Customization Implementation Go live Training User group Hours of operation Disaster recovery Renewal 5

Required Enhancements HIPAA 5010 Coding updates CPT ICD-9-CM (up until October 1, 2013) ICD-10-CM (starting October 1, 2013) Implementation of ICD-10-CM What happens to ICD-9-CM data sets starting October 1, 2013? PQRS E-Prescribing The Fine Print What is included? More importantly what is not included? Matrix of responsibilities Hardware Interfaces Program configuration Financing What happens if vendor goes out of business? Has your attorney reviewed? Are your rights being protected? Initial/addendums/updates and renewal 6

Have a plan Time line Implementation Initial and Upgrades Assign responsibilities/accountabilities Everyone needs to participate Have a budget Designate a super user Testing and going live Program documentation Backup Privacy and Security Considerations Access from remote locations Clinical data integrity and storage E-mail Security requirements Passwords Program/screen timeouts Multiple levels of security By program By job responsibility 7

EMR Documentation Pearls Facilitates completion of medical record at time of patient encounter Legible More complete/accurate documentation Ease of medical record storage/retrieval Reduction in medical errors Likely compliant with 1997 Documentation Guidelines Easier to review (internal and external) Electronic Communication with Payers Medical management Authorizations Claims adjudication Direct submission with payer Indirect submission through clearinghouse 8

EMR Documentation and Coding Temptation to code solely based on meeting documentation guideline bullets Medical necessity versus volume Accuracy Were all template elements performed? By whom? Time based coding Counseling and coordination/prolonged services Pattern documentation (cloning) It May Be An Electronic Record But Medical Necessity Still Rules Medical necessity must support level of service Documentation must support medical necessity 9

Medical Necessity Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. MCPM 100-4 Chap 12-30.6.1 Accurate Documentation Template selection There is a difference between chest pain and constipation What was performed and by whom? Visit components (CC/HPI/PE/MDM) Claw back capabilities? Mismatched documentation Is it or isn t it a positive finding Not all elements captured MDM doesn t include patient s CC and HPI 10

Time Based Documentation Counseling and coordination of care Prolonged services Critical care Therapy services EMR Coding Between Providers Shared visit/incident to in the EMR world Does EMR specify who actually performed which service components? How does a reviewer know? Physician at teaching hospitals 11

Cloning Documentation is considered cloned when each entry in the medical record for a beneficiary is worded exactly like or similar to the previous entries. Cloning also occurs when medical documentation is exactly the same from beneficiary to beneficiary. It would not be expected that every patient had the exact same problem, symptoms, and required the exact same treatment Cloned documentation does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information. All documentation in the medical record must be specific to the patient and her/his situation at the time of the encounter. Cloning of documentation is considered a misrepresentation of the medical necessity requirement for coverage of services. Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made. First Coast Service Options: The Medicare Part A Bulletin Third Quarter 2006 The OIG Wants to Know Medicare has noticed an increased frequency of medical records with identical documentation across services Evaluate extent of potentially inappropriate E&M payments and consistency of E&M medical review determinations Review multiple E&M services for same provider/beneficiary to identify if EHR documentation practices are associated with potentially improper payments Source: 2012 OIG Work Plan 12

IM Initial Outpatient Visit Source: Medicare Part B Physician/Supplier National Data, Calendar Year 2008, 2009 and 2010 IM Established Outpatient Visit Source: Medicare Part B Physician/Supplier National Data, Calendar Year 2008, 2009 and 2010 13

EMR Coding Conundrums Modifier rules and logic? Individual payor rules? Does EMR contain CCI edits? Are they current? Distinct E/M services within global surgical package? Preventive medicine visit? With separate E/M service Without separate E/M service EMR Odds and Ends Time and date stamping? By component (HPI/PMH/PE/MDM) or by entire note? By created and/or finalized date? Can electronic note be pended? How is this documented? When does medical record lock down? As soon as record is closed or set time each day? Non-visit documentation? Phone calls Review of laboratory, radiology and consultations Late entry and amending? New record or an addition to the old record? 14

EMR Coding Concerns Template choices without free-text ability Incomplete documentation Can limit support for medical decision making/necessity Documentation errors Conflicting/wrong Abbreviations Sterile documentation Using easy buttons Documentation Miscues Free texting Macros gone wild Abbreviation misinterpretations Timing is everything EMR coding made easy 15

Coder s Credo Develop clear EMR practice documentation guidelines Educate and evaluate Perform coding audits for documentation accuracy and medical necessity Turn off helpful hints that suggest what additional documentation can be added to increase E/M codes Turn off the EMR s auto select E/M coder Thank You For Further Information Broward Health 303 Southeast 17 th Street Fort Lauderdale, Florida 33316 Website: www.browardhealth.org Email: brappoport@browardhealth.org 16