Gastroenterology Coding Alert

Double check your EMR entries to avoid unnecessary attention.

If you are in the habit of copying documentation while billing E/M services provided by your gastroenterologist, you might be raising a red flag for unwanted scrutiny, as the HHS Office of Inspector General (OIG) has made looking for cloned documentation a priority in 2013.

In the 2013 Work Plan, released in October 2012, the OIG indicates that it intends to go back in time — all the way to 2010, to be exact, when reviewing E/M claims. "We will determine the extent to which CMS made potentially inappropriate payments for E/M services in 2010 and the consistency of E/M medical review determinations," the Work Plan states. The OIG also plans to review multiple E/M notes for each provider to determine whether electronic medical record (EMR) coding errors are created by using cloned notes across services.

Your EMR system may make some things easier for your practice in many ways, but it won’t make your E/M claims entirely "audit-proof." In fact, in some cases, your EMR could be setting you up for an audit or OIG scrutiny.

Make Medical Necessity Your Key Factor

While it may be easy to check boxes or fill in bullets for certain sections in an EMR, the provider notes and documentation need to ultimately explain why the patient is seeing your physician on the specified date of service. The medical record note must record what your provider plans to do for the complaints or condition as well as demonstrate medical necessity.

In black and white: "Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT^® code," CMS says in Section 30.6.1 of the Medicare Claims Processing Manual. Therefore, any documentation of a comprehensive history and exam in an EHR may cause the system to automatically assign 99215, but that doesn’t mean your documentation will back up that code selection.

Keep this in mind: Most coding and billing experts recommend that you not let your EMR do your E/M coding for you. Your EMR can’t judge your physician’s medical decision making. The fact is, when you get audited, the EMR won’t be on the stand in your defense. The EMR won’t pay your take-backs or fines.

Watch for ‘Electronic Upcoding’

In addition to not being audit-proof, the EMR may also create the additional concern of "electronic upcoding" related to templates and cloned documentation. You may enter some elements of the history and physical exam, and the computer may generate a more complete history and physical than may be medically necessary for the complaint or condition the patient presents with. This represents another area of potential EMR coding liability.

Example: "The biggest issue I see in family medicine and internal medicine is that now, with electronic medical records, the physicians are merely ‘clicking and pasting’ to populate fields in the Exam section of the encounter, but not actually doing the work," says Terry A. Fletcher, BS, CPC, CCS-P, CCS, CEMC, CCC, CMSCS, CMC, of Terry Fletcher Consulting, Inc. in Laguna Beach, Calif. "The records start to look like ‘cloned’ records."

Even if your gastroenterologist sees ten patients with abdominal pain on the same date of service, they won’t all have the same history, symptoms, treatment recommendation, or prognosis, so copying documentation from one patient to the next is inappropriate. The notes should be tailored to each patient’s individual case.

If your provider is seeing a patient repeatedly to follow a particular illness or injury, the documentation for each encounter must refer to "what you did today, not going back and just cutting and pasting each time," says Margie Scalley Vaught, CPC, CPC-H, CPC-I, CCS-P, ACS-EM, ACS-OR, healthcare consultant in Chehalis, Wash., in the November 2012 AudioEducator conference "2013 OIG Work Plan for Physician Practice." (Visitwww.audioeducator.com/coding-updates/oig-work-plan-update-for-2013-112812.html to get the entire audioconference)

Change the Documentation Wording

Although you might think of "cloned documentation" as only existing when using EMRs, the truth is that even paper records can be considered "cloned," if they are all worded exactly alike. The answer? Help providers remember to document things based only on the information provided at the patient’s visit and the necessary medical decision making needed to care for the patient at that visit..

"Whether the cloned documentation is handwritten, the result of a pre-printed template, or use electronic health records, cloning of documentation will be considered misrepresentation of the medical necessity requirement for coverage of services," says Carrie Weiss, senior provider education consultant with Palmetto GBA, a Part B MAC in seven states.

Bonus tip: Avoid "follow-up" as a catch-all complaint. All E/M documentation must include a chief complaint, but what your gastroenterologist lists as the chief complaint may not fit your payer’s requirements.

"The chief complaint is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the E/M encounter," Weiss says. "It is typically stated in the patient’s own words. An example would be a sore throat, or chest pain. Just stating ‘follow-up’ is not appropriate."