Health Information Compliance Alert

If your EHR is prompting you to check one more exam area so you can upcode to a higher E/M, you could be on shaky ground.

Practices that are not yet using electronic health records (EHRs) are probably at least considering a switch. EHR systems have been known to streamline your billing processes and patient care, and can reduce expenses for paying transcribers, as well as slash compliance risks due to illegible documentation.

In simplest terms, an EHR is a computer-based patient health record, which replaces paper patient charts and documentation. You typically access the patient's health information over a secure network, which allows for realtime information from various locations including the billing office, the exam room, and/or the front desk.

Most EHR systems include information about patients' current and past health, medical conditions, and medical tests. You may also be able to input, store, and access data about medical referrals, medical treatments, medications, and even demographic information and other non-clinical administrative information.

Improved accuracy: "There are many benefits for moving into an electronic world," says Kathleen Goodwin, CPC, CPMA, LPRN coding coordinator with LaPorte Regional Health System in Indiana. "Data is easily accessible to the necessary people. Doctor's notes are easily read and therefore promoting a higher level of accuracy and lower level of mistakes."

Example: "Let's say a patient is in an accident while on vacation and no one is available to inform the doctor of the patient's special needs (i.e. allergy to penicillin)," Goodwin says. "An EHR system could gather that information and have it available for the doctor prior to treatment."

Financial incentives: The government offers bonus incentive payments to practices that use EHRs. Over a fiveyear period, Medicare will pay up to $44,000 per-physician to "meaningful users" of EHR systems. Physicians who aren't participating in Medicare may be eligible for incentive bonuses from Medicaid. "Medicaid actually offers more incentive money than Medicare for using EHRs," says Leslie Warren with the EMR Advisory Group, a nationwide EHR consulting firm. Although each state makes its own rules regarding patient volume thresholds, the minimum threshold for all eligible professionals except pediatricians is that 30 percent of a practice's patients have to be enrolled in Medicaid to qualify for the incentive.

How much? Eligible professionals can collect up to $63,750 over a six-year period through the Medicaid incentive program.

Many EHR vendors will tout their products by telling your practice that the software can save your coding because it can "prompt" you to document certain findings. For instance, if the diagnosis is dermatitis, but the physician has not documented any integumentary bullets, the EHR might ask the physician whether he's sure he doesn't want to document anything in that section. However, it's important to note that you are still in charge of performing your coding -- no EHR system can replace the doctor's decision-making when documenting services.

"This is a real gray area in the EHR business," says Chip Hart with the Physician's Computer Company, a consulting and software firm. "On one hand, we want to make it easier for providers to record what they've done and even provide them some clinical guidance," he says. For instance, practices often love the EHR feature that prompts the physician to document an important part of the exam.

"On the flip side, having your EHR suggest that you check one more orifice in order to get that 99214 or require only a single mouse-click to make it appear as though you performed a long list of services is dangerous for both the patients and the practices," he says. The documented physical exam should be appropriate to address the presenting problem. Medical necessity is the driver.

The key to striking a balance is education. Make sure your physicians continue to document thoroughly, just as they did with paper records -- that way, your charts are still accurate and complete, whether they are electronic or not.

Some practices may program their EHR systems to carry over information from previous visits -- for instance, if the patient has two siblings with colon cancer, that information might flow into the patient's history from one visit to the next. But you should avoid having all of the documentation transfer from visit to visit, because this could lead to accusations of the physician using "canned" or "cloned" documentation that makes every visit look identical.

Beware: The HHS Office of Inspector General auditors will be looking for "'cloned note' cases where all of a physician's E/M notes look identical because of documentation software," cautions Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa. She notes that the 2011 OIG work plan specifically states that "Medicare contractors have noted an increased frequency of medical records with identical documentation across services."

The plan also states that the OIG will "review multiple E&M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments."

Medical practice management (MPM) systems often integrate, or even come with, EHR systems. While some of the information in an MPM system and an EHR system will overlap -- for example, patient and provider data -- you'll use the EHR system for assisting the providers with clinical data, while you'll use the MPM system for administrative and financial matters.

To avoid problems when linking up your MPM system with your EHR, communication is key. Talk to the vendors from both companies to ensure that the interface will work smoothly, he says.

"The biggest issue from a practical perspective is figuring out which product performs which task in your office," Hart says. "For example, many programs deliver a patient scheduler, but whose scheduler will you use? Does the EHR require the scheduler for the patient portal to work, or does the billing system require the scheduler in order to generate routing information? If you don't use feature XYZ in your EHR, what implications does that have?"