One of the driving factors behind the proliferation of electronic health records (EHRs) was their perceived ability to help physicians document and bill higher levels of Evaluation and Management (E&M) services. An (illogical) set of documentation guidelines provides lists of “buzzwords” that generate credit. In general, more buzzwords equals higher levels of service, which generates more revenue. Because of this, the cost of EHRs was viewed by many organizations as an investment that would provide handsome returns. In regards to compliance, EHRs have missed the mark in a few major ways. Fortunately, minor tweaks can correct most of these deficiencies and provide regulatory insulation.
Problem: “History of Present Illness” (HPI)
The most common limiting factor in chart audits performed by the author is the documented History of Present Illness (HPI). Many notes do not contain enough of the recognized descriptors of HPI to support the level of service reported. Four of the following elements need to be documented in the record to support the most commonly assigned codes: location, quality, severity, duration, timing, context, modifying factors and associated signs/symptoms.
It is helpful to keep the following HPI pointers in mind:
1) Each of the recognized HPI elements is only credited one time by auditors. Therefore, documentation of a single symptom generates the same credit as documentation referencing five symptoms.
2) Both positive and negative responses generate credit. A note establishing that the patient denies any symptoms, that nothing exacerbates their problem, and that their condition is not worse at any specific time of the day generates credit for three HPI variables: symptoms, modifying factors, and timing.
3) The location of a problem, one of the HPI variables, could be self-evident for patients with coronary disease, peripheral vascular disease, carotid disease, aortic aneurysm, tachycardia, systemic hypertension, etc. The disease titles establish where in the patient’s body the present illness is located.
4) The severity of a problem, another HPI variable, could be assigned to potentially every cardiac condition. Class I = IV heart failure and mild/moderate/severe vascular disease are among the most common examples.
An alternative to documenting four HPI elements is to document the status of three or more chronic or inactive conditions in the subjective section of the note. Because the status of these chronic/inactive conditions must be obtained from the patient during the subjective portion of the visit, and documented separate from the assessment and plan, it is not ideal for cardiology encounters. It is preferable to focus exclusively on documenting four of the recognized HPI elements.
Problem: Contradicting Comments
Dictation text blocks, dot phrases, auto-populating medical record fields, and pre-printed check boxes are common shortcuts to creating a note that accurately describes the patient visit. However, when a healthcare professional authenticates a note, he/she is attesting to the accuracy of the information. As such, there should not be contradictions within the document. The presence of them could be interpreted as inappropriate use of a short cut and/or false statements in the medical record. This is important because false statements submitted to federal prosecutors can generate stiffer penalties that fraudulent billing.
The most common contradictions are between the HPI and the Review of Systems (ROS). HPIs are typically dictated or typed by physicians. They are free-form summaries of things that have taken place since the preceding visit. In contrast, ROS documentation is most commonly created with the help of the documentation shortcuts previously summarized. Contradictions commonly happen when patients present with new complaints, like chest pain or shortness of breath. These symptoms are clearly documented in the HPI. But if the physician does not take the time to edit the auto-populated ROS, it will still specify that the patient denies chest pain and shortness of breath.
The fix for this common concern is to change the default text for the cardiovascular and respiratory ROS elements to be non-committal. For both of these ROS elements, change the default text to “negative, except as specified in the HPI.” This approach will ensure credit for the ROS element in a way that does not generate contradictions.
Problem: Physical Exam – Organ Systems vs Body Areas
The documentation guidelines differentiate between “body areas” and “organ systems” when quantifying the level of exam. Body areas and organ systems generate credit for the lowest three levels of exam. Based on current audit standards, most Medicare auditors only award credit for organ systems when auditing services requiring the highest level of exam (like the two highest levels of new patient visits [99204 & 99205] and the highest level of established patient office visits ). The recognized organ systems and body areas are summarized below:
- Recognized organ systems: constitutional, cardiovascular, respiratory, ear, nose, mouth, and throat (ENMT), musculoskeletal, psychiatric, gastrointestinal (GI), gastric ulcer (GU), neuro, skin, eyes, hematologic/immunologic/lymphatic.
- Recognized body areas: head/face, neck, chest/breast, genitalia/groin/buttocks, abdomen, back/spine, and extremity.
Objective exam findings of three organ systems (respiratory, GI, and lymphatic) are occasionally documented in sections of the note that are titled as a body areas (chest, abdomen, and neck, respectively).
- “CHEST: clear to auscultation bilaterally” will most certainly be credited as a chest (body area) exam rather than a respiratory (organ system) exam.
- “ABDOMEN: positive bowel sounds, no hepatosplenomegaly” may be credited as an abdominal (body area) exam rather than a gastrointestinal (organ system) exam.
- “NECK: no lymphadenopathy” may be credited as a neck (body area) exam rather than a lymphatic (organ system) exam.
Although clinically insignificant, classifying organ system objective exam findings as body area exam findings can cause auditors to not award full credit. This is because some auditors complete their audit tool based on the bold section headers rather than reading the objective exam findings and assigning credit based on them.
The fix for this EHR deficiency is to craft default exam templates that prioritize the documentation of recognized organ systems. For many organizations, this could be as simple as changing the header for the chest, abdomen, and neck sections of the note to read respiratory, gastrointestinal, and lymphatic.
Problem: Multiple Authors
The documentation guidelines for E&M services permit documentation of some history components by ancillary staff. The guidelines say, “The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.”
While the documentation guidelines permit documentation generated by ancillary staff, they do not override other, more universal, documentation standards requiring these entries to be authenticated by the author. In many cases, EHRs records contain documentation generated by ancillary staff, but they do not specify the identity of the ancillary staff.
The Medicare Conditions of Participation, Section 482.24, c, 1, requires that “All entries must be legible and complete, and must be authenticated and dated promptly by the person (identified by name and discipline) who is responsible for ordering, providing, or evaluating the service provided. The author of each entry must be identified and must authenticate his or her entry. Authentication may include signatures, written initials or computer signatures.” Non-compliance with the conditions of participation can result in sanction from Medicare.
The Joint Commission standards require that every medical record entry must be dated, its author identified and, when necessary, authenticated. The accreditation status of the hospital may be jeopardized by medical record entries that are not properly authenticated.
“Rules of Evidence” define what documentation is admissible in a court proceeding. Medical documentation is classified as hearsay evidence. Medical documentation is admissible only if every entry is authenticated by the author and the entries are not altered in any way. Because it is impossible to delineate the documentation of the billing provider from that of the ancillary staff member, some EHR-generated documentation might not be admissible in a malpractice lawsuit.
Section 18 of USC 1035 states, “It is a crime to knowingly and willfully falsify or conceal a material fact, or make any materially false statement or use any materially false writing or document in connection with the delivery of or payment for health care benefits, items or services.” Submitting documentation that was created by one person, but authenticated by another may be problematic.
The fix for this problem is not as straightforward as the others. This is because some EHR systems only permit each record to be electronically signed by one person. The right solution for each organization can only be defined after exploring the capabilities of the EHR system, documentation workflow, and possible workarounds.
Jim Collins, CPC, CCC is President of CardiologyCoder.Com, Inc. and the inventor of the OrthoVest — a personal protective device that transfers the weight of lead aprons to the hips. Visit www.MyOrthoVest.com.