Medicare Compliance & Reimbursement

Question: What are some of the potential downsides of a provider filling in some parts of a chart before the patient encounter? One of the providers I work with insists that this is a major time-saver and doesn’t want to listen to my protests that precharting is a compliance nightmare. 

Tennessee Subscriber

Answer: Precharting is a risky endeavor that many coding and billing and compliance managers (and electronic health record [EHR] software) discourage for several reasons. Recording information about an encounter before one sees the patient opens the door to a lot of errors, including no-show situations where the clinician had already begun to describe, in a permanent record, meeting with the patient — which could lead to the provider billing a payer for an encounter that never actually happened.

The Centers for Medicare & Medicaid Services (CMS) says that EHRs require certain precautions surrounding documentation and provides guidance in a fact sheet:

1. “Make sure auto-fill and keyword features are turned off. Watch for “cloned” notes—notes that appear identical for different visits; these may not reflect the uniqueness of the encounter or the patient’s description of their chief complaint.
2. “Make sure all notes have a date and time stamp, even when updating patient history and life events. Separate notes entered at different times by paragraph returns or other clear punctuation or spacing.
3. “Make sure any edits to the patient’s record are also initialed or identified with the person making the edit.”

Including the time and date of any notes in an EHR, as well as the initials or signature of the person making the edit, are best practices for ensuring the accuracy and integrity of the medical record. Auditors may play close attention to dates and time stamps, too.

This also underscores the fact that while a provider may believe that precharting saves time, the effort may not produce payment: When calculating time-based billing to determine an evaluation and management (E/M) level, time spent only on the date of the encounter can be included.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC