BALTIMORE -- Electronic health records make it easier than ever to create detailed patient files even for long or complex encounters but the technology has a dark side: EHR upcoding.

The Centers for Medicare and Medicaid Services, in fact, is more concerned than ever about overcoding – and balancing medical necessity with meaningful use.

It’s no wonder. On the one hand are unscrupulous providers either upcoding or otherwise gaming the system with EHR notes and, on the other, are well-meaning clinicians who inadvertently fall prey to documentation mistakes that put them at odds with the law.

Some doctors are just distracted, lazy or otherwise all too happy to let someone else deal with the hassle of EHR charting. 

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Kim Garner Huey, owner of KGG Coding and Reimbursement Consulting, said she once encountered a coder who told her that one doc was "so bad with his documentation" that he gave the coder his login info – enabling her to have free access to the medical record, and even the ability to enter diagnoses.

That tale, as one might imagine, elicited audible gasps from the AHIMA Convention and Exhibit audience here this week.

As EHR’s approach near-universal adoption, hospitals must focus on data integrity, high-quality clinical documentation, making sure doctors do not upcode improperly just because it’s easier, and for the dreaded audit.  

Garner Huey and Sandra Giangreco, coding compliance audit senior manager with CHAN Healthcare Auditors offered advice during an AHIMA session on avoiding chart note challenges, and gave some perspective on what auditors are looking for when gauging medical necessity.

When auditors come knockin’
Garner Huey said auditors generally look for some telltale signs when examining EHR documentation. They're interested in authentication such as signatures, dates and times – metadata that tells who did what, and when.

They're on the lookout for contradictions between history of present illness and review of systems.

Auditors also tend to be well attuned to certain wording anomalies or grammatical error that might indicate something other than above-board clinical notes.

Another thing they look for: medically implausible documentation.

Configuring code generators and templates
Garner Huey and Giangreco shared questions that hospitals should be asking about code generators and templates.

Has code generating software been programmed to account for policies specific to the local Medicare contractor? How does the coding tool manage dictated portions of the encounter, such as the HPI? And how does it distinguish between different levels of medical decision-making?

With templates, there other questions to consider. Is the provider able to choose only part of a template, or to personalize one? Are there multiple templates, personalized for complaint or diagnosis? Are the various contributors to the encounter – nursing staff, physician, identified?

Pros and cons of copy and paste
Then there's the issue of copy-and-paste. Auditors can see within an EHR where notes have been slapped in from some other source by recognizing unnecessarily lengthy notes, outdated or redundant information or challenges identifying the authors or dates.

But copy-and-paste doesn't always indicate wrongdoing. Giangreco and Garner Huey pointed to a JAMA Internal Medicine paper by researchers form University of Wisconsin.

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"It is too easy, and often mistaken, to equate a physician's routine use of copy-and-paste with fraud," the authors wrote. "Data replication is a feature of electronic health records; facts beyond the mere use of duplicated text are required to establish that a note may be fraudulent."

Indeed, when used correctly, it can create time savings, the JAMA article noted; EHRs are "not to blame for the carelessness of individual physicians."

AHIMA guidelines
AHIMA put forth some of its own guidelines for proper use of copy-and-paste functionality back in 2014, aiming to promote EHR efficiency while still ensuring accuracy and integrity.

Providers, meanwhile, should develop thorough policies and procedures to ensure regulatory compliance and "high-quality clinical documentation and health information integrity."

It should only be done with robust technical and administrative controls, AHIMA officials said, and clinicians should always weigh the time savings against the risk of inaccurate, fraudulent or unwieldy EHR documentation.

To ensure copy-and-paste is used appropriately, AHIMA recommended that providers, vendors, policymakers work together to develop standards for monitoring clinical documentation compliance – and ensuring that EHR systems support it.

Developers should make sure their EHRs are configurable so clinicians can use copy-and-paste accurately – such as enabling recording user actions, audit capabilities and reporting, said AHIMA. And groups such as the Office of the National Coordinator for Health IT and the National Institutes of Standards and Technology should take a more active role in documentation capture processes.

Twitter: @MikeMiliardHITN
Email the writer: mike.miliard@himssmedia.com

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