Pulmonology Coding Alert

Hint: Bring in more revenue with well-trained EHR aficionados at your practice.

Medical practice staff members install and implement new Certified EHR Technology (CEHRT) so physicians and clinical staff utilize it - however, often times, coders, billers, and practice administrators receive minimal training on new technologies, but are expected to use them nonetheless. But their lack of EHR instruction usually leads to compliance and reimbursement headaches down the line, so it's essential to keep your Revenue Cycle Management (RCM) folks in the HIT loop.

History lesson:  Since their earliest days, EHR companies have collaborated closely with doctors and other clinicians to develop their software. This clinical focus seemed to make sense: EHR developers wanted their software to work well for patient care and they knew that physician owners were making the purchase decisions.

Here's the Downside of Clinically-Focused EHRs

Most EHR companies didn't understand the complexities of medical reimbursement and regulatory compliance. Many didn't even think to ask, said Angela Jordan, CPC, COBGC, who spoke at the American Academy of Professional Coders' recent regional conference in Salt Lake City. It's only recently that EHR companies have begun to hire coders and RCM experts to help them design software that integrates well with practice management systems and works just as well for RCM as it does for the clinic, added Jordan, who is an AAPC Fellow and senior management consultant at SCBI.

Small coding and billing glitches that begin in the EHR are sometimes hard to identify before they become big, horrible RCM problems. In extreme cases, flaws with CEHRT or billing software technology and user errors can make providers more vulnerable to fraud risks and cause them to fail documentation audits.

As software development continues, we hope that good EHR and billing systems will work better in clinical settings and in the back office. But what can RCM staff do in the meantime to improve documentation, prevent coding and billing errors, and reduce compliance risks? Jordan urged coders and billers to take the following steps.

Step 1: Remember to Address MAC Guidelines Upfront

Understand what your Medicare carrier and your other major payers have to say about EHR and billing systems. MAC guidelines aren't all the same, Jordan said, so you should educate yourself on your carrier's instructions. Despite the differences, carriers agree on some general principles, which Jordan outlined in her presentation.

Tip:  For example, be careful to avoid "double-dipping." Some carriers explicitly forbid using the same data point in two different parts of the medical record.

Step 2: Beware of Cut-and-Paste Options

Be very wary of documentation templates that come with the software. Some EHR systems "auto-populate" parts of the medical record with information that is not specific to the patient, especially in the HPI section.

Jordan shared Noridian's statement about such "auto-populate" features: "Auto-populated paragraphs provide useful information such as the etiology, standards of practice, and general goals of a particular diagnosis. However, they are generalization and do not support medically necessary information that correlates to the management of a particular patient ... Credit cannot be granted for information that is not patient-specific and date-of-service-specific."

If your RCM team works directly with your EHR vendor to create customized documentation templates for your practice, you can get better data from clinicians which will help you code and bill correctly and reduce compliance risks.

Tip: Educate clinicians about the risks of "cut-and-paste." Practices spend so much money on software that they often skimp on training, Jordan warned. Because of this lack of in-house education, bad documentation habits sometimes develop that can cause big problems should auditors request records for review. Jordan referred to a health system's problem she's familiar with, where providers have been pulling the exact same assessment and plan from visit to visit - a habit that is causing big compliance headaches.

Jargon alert: Other terms for user errors similar to "cut and paste" are "medical plagiarism" and "cloned notes."

Step 3: Transfer Data Not Bad Habits During EHR Transitions

Watch for bad habits that providers develop as they adjust to new systems and devices. Let's face it - most EHR systems are not as user-friendly as technologies outside of healthcare that we all use every day. It's easy to see why clinicians develop informal workarounds that make it easier for them to use the EHR and focus on instead on their patients. Unfortunately, sometimes clinicians share these moves among themselves without considering the compliance implications.

For example: Some doctors insert disclaimers into their notes such as "I dictated this in Dragon so please disregard any errors." Disclaimers like this basically say, "I know I made mistakes and didn't proofread, but just ignore them." Payers and auditors, of course, do not like this, Jordan cautioned.

Step 4: Know the Specifics on Time-Based Codes

Watch out for how your EHR system handles time-based codes. Some EHRs have pop-ups designed to help providers estimate time. If clinicians select only the time, the result can be a progress note with no supporting documentation in it, Jordan warned.

Step 5: Ensure Your EHR Doesn't Backdate

Don't let your EHR allow backdating. Some EHRs still allow clinicians to backdate records, Jordan said. If your EHR still does that, you need to ask your vendor to prevent backdating. That way any auditor can clearly see when the record originated and when corrections were made. If clinicians need to go back to a medical record to add more information, they need to do an addendum, Jordan stressed. Noridian, for example, says that corrections should contain "the current date, time, reason for the change, and initials of the person making the correction."

Step 6: Use an EHR with Updated Electronic Signature Requirements

Double-check to make sure that the electronic signatures built into the system also contain provider credentials. A typical group practice has physicians, non-physician practitioners, medical students, nurses, and scribes all working with the medical record. MAC guidelines vary considerably by jurisdiction regarding which clinicians can perform, document, and sign off on each part. It's crucial that electronic signatures also list credentials, so that auditors can tell who was qualified to do what.

Important: During implementation, some EHR companies set up electronic signatures and tell the practice it can add credentials if it wants to, Jordan warned. It's not really a matter of choice, and this step is easily forgotten during the difficult work of implementing an EHR in a practice. Insist that electronic signatures include credentials during set-up.

Step 7: Train Coders and Billers on EHR Technologies, Too

A good EHR and billing system can automate and simplify some RCM functions, but it takes a knowledgeable human to spot problems, trace their causes, and make sure the software is doing what it should for RCM. Proper training makes every member of your staff indispensable, so it's critical that coders and billers especially understand the nuances of your practice's EHR and PM systems to avoid confusion - and to ensure the practice gets the reimbursement its earned.