Audit Hotspot #1: Copy and Paste
EMR shortcuts for copy and paste may lead to many errors, not only in record-keeping and accounting, but also in automated carry-forwards that can negatively impact a patient’s treatment. Add a chronic or acute illness into the mix—mistakenly copied from past history—and the patient could be denied insurance coverage based on allegedly falsifying information. A simple EMR error and the patient can no longer afford medical treatment.
Abuse of the copy and paste feature is indefensible in a court of law. Notes and records that can’t be substantiated or later proven via an accurate clinical assessment of the patient puts the entirety of care received into question, not to mention the reputation of the physician and the practice.
The risk is easily mitigated on the front end by taking the time to verify all notes for accuracy and specificity to the patient. Providers who wish to benefit from the time-saving features of an EMR’s copy and paste feature, or other time-saving functionality, must be willing to ensure that those time-savers don’t later cost him time, money, lost patients, and more.
Steer clear of other risks with copy and paste:
Tip: A single well-written paragraph can tell the reader everything pertinent to the patient, which two pages of duplicated information may not convey.
Audit Hotspot #2: Drop-down Boxes
EMRs offer drop-down boxes designed to enable physicians to easily call up a list of common (or specific to that specialty) complaints or presenting problems. For all their benefits, though, drop-down boxes readily lend themselves to mistakes.
Patients often come in with multiple concerns, all of which they discuss during their visit. Problems arise when drop-down menu options do not fully, or precisely, align with the reason for the visit.
Example: The provider may inadvertently choose a medication to prescribe from the drop-down menu that the patient is allergic to without verifying it with the patient. This error can have immediate consequences for the patient.
Example: A patient indicates on the health history form that he takes Tramadol. The provider mistakenly documents, using a drop-down menu, that the patient has no medical history or current use of medications. Since the patient has a current and active prescription for Tramadol, the physician’s own notes reveal that he has not read the patient’s health history form.
New vs. established patients
Another negative consequence of drop-down boxes can occur if a patient is not identified on the medical record as a new patient on the initial visit. Providers, then, would not be able to choose the documentation options related to a new patient visit.
Be careful, though, as patients aren’t always as new as they might seem.
Providers follow the never-seen-before or the three-year rule to determine whether the patient should be identified as a new patient. In larger multi-specialty group practices, a patient is new when seeing a physician of a different specialty in the same group.
Audit Hotspot #3: Inappropriate Documentation
Review of Systems (ROS)
A complete ROS may not be necessary for all patients. This is where auto-populating of information can turn problematic because the EMR may extract information from the ROS of the patient’s previous visit. Because a computer can’t rationalize and tell a provider whether the facts supporting medical necessity for the intervention are adequate or appropriate, the provider needs to be vigilant when checking documentation to ensure the components of the ROS are applicable to the patient’s condition.
When documenting elements of the exam, the provider should ask if those elements meet medical necessity and double check all elements if using an auto-populate feature to document. Some providers document the same elements of an assessment, such as a hearing test, gait and station, or external examination of ears and nose on all patients who present for an examination, regardless of what work is required to investigate their complaints.
Watch out for other problem spots:
Example: A provider documents an ROS for 10 systems with a comprehensive history and reports 99214 with a diagnosis of ringworm.
Caution: Sometimes the provider does not document the primary diagnosis for the visit. This may be because EMRs often list all of the chronic diagnoses, carried over from previous visits, even if the provider does not address them during that visit. The provider then neglects to document the primary diagnosis, which may lead to assigning a higher level procedure code for the visit.
Audit Hotspot #4: Auto-Populate
The single click of a checkbox, resulting in auto-population of data into EHR fields, can generate erroneous documentation into a patient’s record. The OIG describes over-documentation as inserting false or irrelevant information on a record to support a bill for more expensive services. While OIG investigators recognize that these errors may occur in EMRs by auto-populating fields, the onus of responsibility falls to the provider.
Every EMR system is different, and not every system will predispose a provider to errors. However, clinicians should maintain a healthy sense of caution about common EMR pitfalls. Self-verification and self-audit are the two most important measures practices can take to identify and remediate these issues.
Master accurate and timely documentation that reflects the scope of services provided with TCI’s Clinical Documentation Sourcebook 2018.