Technology

Are There Documentation Dangers Lurking in Your EMR?

Cloning claimsmay raise red flags.

By Paul M. Larson, MBA, MMSc, COMT, COE, CPC, CPMA

There’s no question that Electronic Medical Records (EMR) can be an amazing resource for your patients and the practice. However, did you know EMR systems have security, privacy, financial, and malpractice risks as well? In EMR systems, It has become particularly easy to code visits as a 4 or 5 merely by “clicking” on various examination elements that appear on the computer screen. The resulting chart printouts look like all tests have been performed at each and every one of the patient’s visits—and we know that’s rarely true. Payers are watching closely for fraud and abuse, so it behooves us to be sure the chart accurately representation of the work and thoughts of the providers on that visit.

The Hidden Threat of Cloning

We all know how security can be compromised on EMR. Just as we don’t leave paper records out for anyone to see, it makes sense not to leave electronic records “open” – even for just a moment. Additionally, mobile devices such as smartphones, tablets, and laptops with access to your EMR are under constant threat of theft. In an unusual twist, hackers have even held some practices EMR data hostage.

These real and serious threats are easily understood, but some aspects of EMR we take for granted are creating a new threat. It may seem more efficient, but documentation that does not represent what actually transpired during a patient encounter can threaten a practice. CMS and other payers have been warning about cloning notes in EMR for more than two years, but as EMR use expands, investigators with the Office of the Inspector General (OIG), as well as most payers, have taken notice. The 2012 OIG Work Plan noted they would “review … services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments. Medicare contractors have noted an increased frequency of medical records with identical documentation across services.” This statement of concern speaks specifically to the tendency to “copy-forward” information from a previous visit and “clone it.”

Some EMR systems even have options that allow copy-forward in commonly cloned areas such as the “problem list,” the history. It’s a key time-saver for EMR users and EMR vendors would not sell many systems without this feature. While not entirely bad (think how similar most cataract operative notes have been for years), it does call into question the veracity of notes where things may change. If all of the history elements, such as all 14 Review of Systems areas, are not actually asked or they don’t all apply to the day’s visit, it would be improper to create a note that misrepresents the service. Be sure you can defend the need for all cloned information – or, if you doubt the note’s believability, start from scratch and ask the patient directly. It may not be as easy as cloning, but it will be more accurate.

Unintended Consequence

Let’s look at an unintended consequence of the move to EMR. Some providers have the capability (because the notes appear to show everything was done) to choose a higher paying code. The higher codes may or may not be justified. Some providers did not document well on paper, although the services they delivered were at a higher level than they billed. For them, EMR is a more accurate note. It’s also likely that, for many practices, they are providing documentation for the sole purpose of meeting higher service levels. Payers know what practices have billed in the past and they already have a high index for suspicion of fraud and abuse upon seeing sudden changes in billing patterns. They might request “proof,” which may begin as a request for a number of visits or as a notice from the payer that their utilization of certain codes is “outside the norm.”

What can you do to prevent this? The answer is to have the EMR show only the work that is done and relevant for that particular visit. Anything copied forward should be actually used in the examination, diagnosis, and treatment of the patient. Medical necessity, the number one driver of your services, is then fully supported. Proper code selection follows and is made more accurate. Payers who ask for your documentation may not tell you when you’ve done well, but they may quit asking. You can take that as evidence they believe what you document.

EMRs are a powerful tool – but they have downsides as well. Use them appropriately as you would any tool in caring for your patients. OP

Mr. Larson is a senior consultant with Corcoran Consulting Group. He has more than 35 years experience in ophthalmology and has served as both program director and faculty member for ophthalmic technology training programs. He can be contacted at (800) 399-6565, ext 224, or plarson@corcoranccg.com.