- Providers should not let the EMR code for them.
If it does, the providers need to override the system and only use it as a guide. The EMR is not equipped to understand nuances of medical-decision making that only a provider could determine.
- Say yes to scribes.
If a provider is hard-pressed for time or is reluctant to enter information into the EMR, it is acceptable for scribes – often medical assistants – to assist her. These valuable employees can enter the information as the physician is talking to the patient –thereby decreasing the amount of documenting from the physician.
- Providers must double check for discrepancies.
Checking for discrepancies also includes verifying the work of the scribe to ensure the accuracy of the information and eliminate any discrepancies between the CC, HPI, ROS, and PE.
- Beware of template typos.
These types of errors can be dangerous especially when they are part of the template, as can be the case in successive charts. Auditors are especially wary of the liability issues they cause.
Remember: The goal of a template is to ensure accurate documentation that does not cause providers to use the same template answers for every patient.
- Expand on templates.
Best Practice: Providers should create two different note templates to use so that the problem visit documentation does not lie within the body of the wellness visit note. This will depend on the EMR. Some EMRs can help create two different visits within the system. Others will allow the provider to make edits and alterations to one main template.
- Example: If the provider is a primary care physician, or an ob-gyn, how can he claim for the time billed on an office visit and wellness visit, when both occurred on the same day? The provider will need to maintain separate notes, just in case.
- Keep a hit list for the most common procedures.
- Create a comprehensive template of keywords, with a section that is universally applicable and a section that may be customized based on the patient. Providers can use this template to insert the information into customizable pieces and then tailor it according to the unique needs of each patient.
- Interface EMRs/EHRs.
- If a coder is able to import the physician’s op reports from the hospital’s EHR into the office EMR, she will help to facilitate greater accuracy in coding for surgeries and also capture more of the revenue due to the provider.
- The devil’s in the detail.
- Best Practice: Small points make a huge difference in ensuring that documentation in the patient’s record is thorough and accurate. The patient’s name, DOB, and physician’s name should be on every page. If it’s not printing out that way, contact the technical support team for your EMR and ask them to create a solution.
- Bird’s Eye View: Some auditors will focus on a selection of notes to check that basic demographic and physician information is readily available.
- Documentation should support the ICD-10-CM code for the service/ procedure.
- Providers and coders, together, need to ensure that there are keywords in the documentation that equate to and support the assigned diagnosis. Remember the old adage: Not documented, not done.
- Master improvements with self-audits.
- Practices can start self-auditing for their providers to encourage awareness on the importance of strategic keywords in documentation that facilitate accuracy and precision of coding.
Tip: Start with terms like ‘acute’ versus ‘chronic.’ Ensure that the provider is using these terms accurately and documenting appropriately to support the distinction.
Master accurate and timely documentation that reflects the scope of services provided with TCI’s Clinical Documentation Sourcebook 2018.