Coding

Avoid EHR Stumbling Blocks

Being aware of common EHR missteps can help you avoid them.

By Patricia Kennedy, COMT, CPC, COE,

Electronic Health Records (EHR) are simultaneously a blessing and a curse. While they provide legible and more comprehensive documentation, they can also lead to erroneous findings, up-coding and overall implausible record keeping.

This article will cover the more common errors seen from an auditor’s prospective.

Cloning Documentation

It is not uncommon to find many visits across the patient population nearly identical in documentation and level of service. Most EHR systems have the capability to pull forward the findings from a previous exam and populate the fields on the current visit. There are several problems with this practice.

1. Something may have changed from the previous visit that was not documented as having changed on this visit. For example: a lens finding of a “1+ NS,” but the patient has had cataract surgery in the interim.

2. There may not be medical necessity to “repeat” all the exam elements from the previous exam for the presenting problem on the current visit. For example: performing an extraocular motility on a patient returning for a follow up on blepharoconjunctivitis would be difficult to defend as medically necessary in the absence of a new and related complaint.

3. A finding brought forward lacks specificity to support the plan. For example: both lens findings are documented as “PCO.” Yet the plan indicates the patient is going to undergo a YAG capsulotomy. This minimal objective finding would not suffice in review.

Some Medicare contractors have begun warning providers this practice of cloning documentation is unacceptable.

Pre-Populating Fields with Default Values

Similar to cloning documentation is the practice of checking a box that populates all fields with “normal” findings. Again, we find several problems.

1. The presumption is that the provider has actually performed all the elements marked as having been done and those findings that were not normal have been modified. However, the patient complaint may not justify the completion of all those elements.

2. The “normal” finding is contradicted by a diagnostic test. For example, a confrontation visual field was marked as “full” for each eye, yet the automated visual field shows an enormous field cut from advanced glaucoma.

3. A condition present in a previous record has miraculously resolved without treatment or surgical intervention.

For example, the lids and lashes are marked as being of “normal position and appearance” when the patient previously had significant dermatochalasis with hooding.

Up-Coding and Over-Billing Services.

Most EHR systems have the ability to suggest a CPT code for billing and some practices rely on that for claim submission. If the provider or technician have autopopulated fields without regard to the patient’s presenting problem, the result will be a higher code than medically necessary. OP

Ms. Kennedy, COMT, CPC, COE has been working in the ophthalmology and optometry industry for more 27 years. She is senior consultant for Rose & Associate Healthcare Consultants in Duncanville, Texas.