Audit Hotspot #1: Copy and Paste
Although templates are intended to save time, providers must ensure that the built-in forms are age and gender appropriate. The following example demonstrates how template-assisted documentation might backfire when applied to a pediatric case.
Example: A nine-year-old is seen for burning upon urination and is diagnosed with acute cystitis.
Plan: Rx meds as directed. Instruct patient of safe use of meds, purpose, dosage, importance of finishing prescribed medications, and possible toxic effects. Increase PO fluids, limit caffeine. Wipe from front to back, void frequently and after sexual intercourse. Patient verbalized understanding.
What’s Wrong with This Documentation? Notations about “sexual intercourse” in a pre-adolescent’s file are dead giveaways for copy and paste abuse.
EMR shortcuts for copy and paste may lead to many errors, not only in record-keeping and accounting, but in automated carry-forwards that can negatively impact a patient’s treatment if erroneous information is documented. As well, it can lead to complications with patient’s insurance coverage and lead the payer to deny coverage.
Pitfall: Abuse of the copy and paste feature is indefensible in a court of law. Notes and records that cannot be substantiated or later proven via an accurate clinical assessment of the patient calls the entirety of the 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.
Don’t overlook: According to the OIG website, “When clinicians cut/paste or clone information without updating or verifying, inaccurate information may enter the patient’s medical record, and inappropriate changes may be billed to patient and third-party payers.”
OIG also says, “It … could be used for creation of fraudulent claims as well.” An entirely copied and pasted visit greatly affects the integrity of the associated note and subsequent services rendered as a result of that note.
Steer clear of other risks with copy and paste:
Tip: The best way to avoid these types of errors is each morning, the provider should complete a review of the previous day’s records to identify copy and paste issues.
Audit Hotspot #2: Drop-down Boxes
Among other conveniences, EMRs offer drop-down boxes designed to enable physicians to quickly and easily call up a list of common (or specific to that specialty) complaints or presenting problems.
However, 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.
When good intentions go awry
The drop-down box feature, for all its benefits, readily lends itself to easy mistakes.
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 adverse consequences on the care the patient receives.
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 would then 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.
Here’s the catch
Providers follow the never seen before or the three-year rule to determine whether the patient should be identified as a new patient. A new patient is one who has never seen the physician or has not seen the physician in the past three years. In a larger group practice with physicians of different specialties, a patient is new when seeing a physician of a different specialty, even if another physician in the practice saw the patient in the past three years.
An established patient is a patient who saw the same physician in the past three years. An established patient is also one visiting a large group practice to see a different physician who is the same specialty as the previous physician the patient saw.
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 cannot rationalize and cannot 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 that 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 resolve or 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.
Every EMR system is different, and not every system will predispose a provider to make errors. However, clinicians should maintain awareness and a healthy sense of caution about common EMR pitfalls. Self-verification and self-audit are the two most important measures practices must take to identify and remediate these possible issues.
Master accurate and timely documentation that reflects the scope of services provided with TCI’s Clinical Documentation Sourcebook 2018.