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Template transgressions

Electronic charting can cause major ICD-9 coding and compliance headaches.

June 2013

Published in the June 2013 issue of Todays Hospitalist

OVER THE NEXT FEW YEARS, our health care system is phasing out transcription services as we transition from one electronic health record (EHR) to another. Handwritten progress notes will go by the wayside, and all charting will occur electronically.

Electronic charting has many advantages: It occurs in real time with no lag for transcription, it’s completely legible and it may reduce costs by eliminating transcriptionists. On the flip side, it can be a huge physician dissatisfier because most doctors dictate much faster than they can type. And it can cause major coding and compliance headaches.

We first explored this subject in our July 2011 column, “Checklists: the good, the bad and the in-between.” The Centers for Medicare and Medicaid Services (CMS) recently issued new guidance in March 2013 in its “Program Integrity Manual.” Here are some updates for hospitalists.

Although free-text documentation is always an option, electronic documentation is usually driven by templates. The CMS defines templates as “a tool/instrument/interface that assists in documenting a progress note.” It further states that templates may take the form of:

  • simple electronic documents;
  • sophisticated graphical user interfaces with clinical decision and documentation;
  • support prompts; or
  • electronic pen capture devices.Theoretically, templates can improve patient care by alerting providers to problems they might have overlooked. But templates can also cause a lot of trouble, leading to inadequate medical documentation or, perversely, too much. Either can expose hospitals to audits from third-party payers.Too little documentation
    The CMS’ March guidance stated that it does “not endorse or approve any particular templates. A physician/LCMP [licensed/certified medical practitioner] may choose any template to assist in documenting medical information.”

    That said, the CMS does have definite thoughts about template architecture. The new guidance notes that “some templates provide limited options and/or space for the collection of information such as by using ‘check boxes,’ predefined answers, limited space to enter information, etc. CMS discourages the use of such templates.”

    The CMS also knows that some templates are geared more toward reimbursement than clinical goals. The agency gives the following warning: “physician/LCMPs should be aware that templates designed to gather selected information focused primarily for reimbursement purposes are often insufficient to …. adequately show that the medical necessity criteria for the item/service are met.”

    In other words, the onus is on providers to augment skimpy templates with free text. This can be a real challenge in the rattle and hum of busy clinical practice.

    Too much
    Conversely, some templates contain way too much texture. Chances are, your standard examination of the eyes, for example, doesn’t conform to the information loaded into your EHR. Click on “normal,” and an EHR might chart all manner of things for you: no hyphema, normal cup-to-disc ratio, no AV nicking and more.

    For hospitalists, this capacity can create a big coding-clinical disconnect. You examined the patient’s eyes, so you should receive credit for that exam when assigning a level of service. From a clinical standpoint, however, it’s a big no-no to chart stuff that you didn’t do or wasn’t there.

    The scrupulous physician will edit the autocharted material, but this takes a lot of time and attention. We’ve all seen improbable text in the EHR that can probably be traced back to a radio button that exploded into something much bigger than the physician intended. Potential solutions include free text charting and creating custom templates, but only if your EHR supports such activity.

    Medical necessity
    Hospitalists would never order an MRI scan unless it was medically necessary. Ditto for laboratory studies. But that can all change at the bedside where physicians may not think as much about medical necessity and instead go with their standard scripts for review of systems and phys ical exam.

    Asking a patient with a femoral neck fracture about polydipsia? Probably a stretch. Cranial nerve examination on a patient with a diverticular abscess? Abuse, for sure, and potentially fraud.

    That last one doesn’t compute for most hospitalists. MRI scans cost thousands of dollars, but cranial nerve examination is just words on paper. What’s the big deal?

    Physicians charge for their services, and these charges are a mash-up of history, physical examination and medical decision-making. More data and thinking equal a higher charge.

    A dubious cranial nerve exam could easily move your H&P from a 99222 to a 99223. Here in Minnesota, the difference between those two service levels is about $62 in Medicare money. Petty theft, perhaps, compared to a bogus MRI scan, but theft nonetheless.

    This is definitely on the radar of the CMS. It has instructed auditors to look closely at the patient’s chief complaint and comorbidities to see whether there is medical necessity for all the charted data. Superfluous items, collected either by you or barfed out by your EHR, risk denial of service.

    Copy forward
    Another pernicious problem with EHRs is the “copy forward” or “copy and paste” function. These allow providers to lift chunks of data from other places in the EHR and drop them into their documentation.

    While nifty, these functions beg the whole medical-necessity question. You scratch your head when you see a family history or social history in every progress note. A new problem might have developed that warranted reviewing them, but that is extremely doubtful. No matter what the coding wizard built into your EHR tells you, don’t expect to get credit for charting these.

    Then there is silly stuff like “normal EKG,” which seems to appear in every progress note. If you drill down into the medical record, probably just one EKG early in the hospital course has been copied forward every day.

    There is also the completely absurd. Not long ago, we saw a biophysical profile in a progress note on a woman who had delivered weeks before. Remarkably, the phantom fetus scored 8 out of 10.

    The CMS is wise to all of this. Several of its audit contractors have published information indicating that the use of these features may not support seeing the patient on a daily basis. Why? Because it appears, in the EHR at least, as if nothing about the patient’s condition or the management of his or her problems ever change because every progress note reads the same.

    The only real solution here is conscientious editing. Delete irrelevant and repetitive material. Update your history, physical examination and medical decision-making. Make sure lab and imaging data are specific to today’s encounter.

    Cost savings?
    This probably sounds like a lot of work and, frankly, it is. Although EHRs generally tout various cost savings, we’re not convinced, at least on this one.

    Unfortunately, savings often come from cutting corners that can cost you dearly during a later audit. Templates can be a nice starting point for medical documentation, but they still require clinicians to invest a fair amount of time to produce polished notes.

    David Frenz, MD, is a hospitalist for HealthEast Care System and is board certified in both family medicine and addiction medicine. (You can learn more about him and his work at www.davidfrenz.com.) Sue A. Lewis, RN, CPC, PCS, is a compliance consultant with HealthEast Care System.