Is Your Electronic Health Record Putting You at Risk for a Documentation Audit?

A group of 3 busy orthopedists attended coding education each year and did their best to accurately code and document their services. As a risk-reduction strategy, the group engaged our firm to conduct an audit to determine whether they were documenting their services properly and to provide feedback about how they could improve.

What we found was shocking to the surgeons, but all too common, as we review thousands of orthopedic visit notes every year: The same examination had been documented for all visits, with physicians stating in their notes that the examination was medically necessary. In addition, their documentation supported Current Procedural Terminology (CPT) code 99214 at every visit, with visit frequencies of 2 weeks to 4 months.

The culprit of all this sameness? The practice’s electronic health record (EHR).

“Practices with EHRs often have a large volume of visit notes that look almost identical for a patient who is seen for multiple visits,” explains Mary LeGrand, RN, MA, CCS-P, CPC, KarenZupko & Associates consultant and coding educator. “And that is putting physicians at higher risk of being audited or of not passing an audit.”

According to LeGrand, this is because physicians are using the practice’s EHR to “pull forward” the patient’s previous visit note for the current visit, but failing to customize it for the current visit. The unintended consequence of this workflow efficiency is twofold:

1. It creates documentation that looks strikingly similar to, if not exactly like, the patient’s last billed visit note. This is often referred to as note “cloning.”

2. It creates documentation that includes a lot of unnecessary detail that, even if delivered and documented, doesn’t match the medical necessity of the visit, based on the history of present illness statements.

Both of these things can come back to bite you.

Zero in on the Risk

If your practice has an EHR, it is important that you evaluate whether certain workflow efficiency features are putting the practice at risk. You do not necessarily need to dump the EHR, but you may need to take action to reduce the risk of using these features.

In a pre-EHR practice, physicians began each visit with a blank piece of paper or dictated the entire visit. Then along came EHR vendors who, in an effort to make things easier and more efficient, created visit templates and the ability to “pull forward” the last visit note and use it as a basis for the current visit. The intention was always that physicians would modify it based on the current visit. But the reality is that physicians are busy, editing is time-consuming, and the unintended consequence is cloning.

“If you pull in unnecessary history or exam information from a previous visit that’s not relevant to the current visit, you can get dinged in an audit for not customizing the note to the patient’s specific presenting complaint,” LeGrand explains, “or, for attempting to bill a higher-level code by unintentionally padding the note with irrelevant information. What is documented for ‘reference’ has to be separated from what can be used to select the level of service.”

Your first documentation risk-reduction strategy is to review notes and look for signs of cloning.

LeGrand explains that a practice may be predisposed to cloning simply because of the way the EHR templates and workflow were set up when the system was implemented. “But,” she says, “‘the EHR made me do it’ defense won’t hold water, because it’s still the physician’s responsibility to customize or remove the information from templates and make the note unique to the visit.”

Yes, physician time is precious. But the reality is that the onus is on the physician to integrate EHR features with clinic workflow and to follow documentation rules.

The second documentation risk-reduction strategy is to make sure the level of evaluation and management (E/M) service billed is supported by medical necessity, not only by documentation artifacts that were relevant to the patient in the past but irrelevant to his or her current presenting complaint or condition.

“Medicare won’t pay for services that aren’t supported by medical necessity,” says LeGrand, “and you can’t achieve medical necessity by simply documenting additional E/M elements.”

This has always been the rule, LeGrand says. “But with the increased use of EHRs, and templates that automatically document visit elements and drive visits to a higher level of service, the Centers for Medicare & Medicaid Services [CMS] and private payers have added scrutiny to medical necessity reviews. They want to validate that higher-level visits billed indeed required a higher level of history and/or exam.”