When I was small (very, very young, of course) and the highway system not quite so developed, I remember seeing signs that read: "Warning  Muddy Roads Ahead."  I think of this phrase as I am performing the "baseline" audits for Medical Practices in preparation for the upcoming mandatory Compliance Program for Physician offices.  Although the final regulations have not been issued for our sector, we know that the required program, under the Affordable Care Act, will be at least as strong as the plan recommended by CMS in the October 2000 edition published in the Federal Register.  However, with the errors that are being uncovered in medical record documentation under the Comprehensive Error Rate Testing Program (CERT) and the RAC audits, we feel that it will be even more stringent.

One of the first things that the government recommends is the performance of a "baseline audit" for each medical practice to assess both the good and "not-so-good" elements found in your physician's/provider's documentation.  Based on the result of these findings, your individual plan is then to be structured in ways to build on the strong points and correct any deficiencies found in the review.  CMS recommends that practices perform this baseline audit on a minimum of 5 records per provider per Federal carrier.  However, most offices are also including private carrier audits as well.  Annual audits using the same criteria are also recommended to be performed on an annual basis for compliance.

This is the electronic age and we are becoming more dependent on our front desk personnel, nurses, medical assistants, and providers to enter the information required to bill out the patient visit.  I am continually surprised, and even appalled, at some of the findings that I am uncovering in the audits.  I fear that we may be heading for major problems in the content of our electronic health records if we don't address these problems in the near future.  Many of my physician practices are reporting that their physicians are not even referring to some of the EHR notes that they are receiving from referring physicians stating that often the records do not even make sense!  Unfortunately, that is exactly some of the results that auditors are addressing. 
I first saw an example of this about three or four years ago when one of my fellow instructors/mentors, Regina Mixon Bates, IRO, TPA, CPC, CPC-I, CMC, CMOM, CMIS, presented  a copy of one of her physician visit notes during a presentation on Chart Auditing at Practice Management Institute's (PMI) National Conference. Fortunately, Regina is a cancer survivor.  In the visit that she referenced, she had presented to the physician's office with new symptoms.  This could have been very important information in her treatment process.  However, because information in the notes had been "cut and pasted" from her previous visit, some of the important facts surrounding the current visit were "lost" in the progress notes.  Regina is the CEO of The Physicians Practice SOS Group operating out of Atlanta, Georgia.  I have learned a lot from her over the past few years as we discuss auditing and documentation standards.  This was one conference presentation that pointed out very clearly an issue I think is so important to consider as we move further into electronic health records.

Here are some examples of other issues that I am currently discovering in my audit assignments:

1.  Computer "glitches."  One such example: the practice has a patient portal in which the patient enters information regarding the Chief Complaint and History of the Present Illness and Review of the Systems.  As the Medical Assistants interview the patient to firm up this information and clarify it, they enter the information they gather in the electronic health record.  The computer creates a new "bulleted" item as the MAs enter their information, in essence creating a "new problem" which is used to calculate the level of care in the system, thus, "bumping" up the level of the visit resulting in "overcoding."

2.  In the ROS, the system for which the patient is presenting with a complaint is marked "normal."  For example, a record in which the "Chief Complaint" was "lower back pain with pain radiating into the leg," the Musculoskeletal System in the Review of the Systems was marked "normal."  Medicare would not allow credit for the review of the Musculoskeletal System for such documentation.

3.  The "Chief Complaint" entered as "Follow-up."  CMS states that the "Chief Complaint and the HPI contextualize" the remainder of the documentation of the visit, thus substantiating "medical necessity."  If the chief complaint is not complete, the medical necessity for reviewing the various systems in both the Review of the Systems and in the Examination may not be justified.   In addition, CMS states that the words "follow-up," without indication as to the problem, is deficient in establishing the need for the visit at all. 

Basically, these issues represent some changes in the last year in the way that CMS indicates that a record should be reviewed for medical necessity.  As a result, my complete approach to the auditing of the medical record has had to change.  In the past, if the notes documented that the individual systems were reviewed, we gave credit for each system so indicated.  Now, CMS states that you must show the necessity in the Chief Complaint, the ROS, or in documented problem(s) uncovered in the Exam  to indicate the need to review a particular system  or you will not receive credit for reviewing the system.  This could result in bringing the HPI and/or ROS down to a lower level upon audit.  Because the History component may be reduced to a lower level, this would result in bringing the level for the entire visit down for a new patient based on the documented facts.

4.  Similar to #2 above, the system relating to the Chief Complaint, HPI and ROS may be shown as "normal" under the Examination portion of the visit.  This certainly "muddies the water" when trying to read and decipher what was going on with the patient.  Also important, this represents an item that CMS would not allow credit for in the examination for the system during a review of the patient's record.  Many times these errors are occurring as a result of information being "carried forward" from a previous visit.

Having worked for physicians for many years, I totally understand their frustrations in regards to Evaluation and Management documentation.  They received no training in this area, and yet, their livelihood can be heavily impacted based on the outcome of a review by a RAC auditor that can go back 3 years to review past records.  Physician's have had so many responsibilities added to their role that it seems to impact the time available for patient care  which is what they are most interested in.

5.  The official Documentation Guidelines state that requirements for an Extended HPI can be met by documenting the status of three inactive or chronic conditions.  However, it will not justify an Extended HPI to simply mention that the patient is presenting with, for example, Diabetes, Hyperlipidemia, and Hypertension.  The notes must indicate the "status" of the conditions.  In other words, the status of each condition as compared to the last time the patient was seen.  Often, this detailed information is lacking, which would result, again, in the possible lowering of the level of the History component.
These are but a few of the types of examples that I could cite.  However, CMS has issued guidelines to use when reviewing the documentation in your office.  In the enclosed article entitled, "Part B Tips for Preventing Most Common E/M Service Coding Errors" from the Trailblazer Health Enterprises/CMS website, you can review one important resource from CMS and the MAC Carriers that can be used and  referenced when presenting this information to Providers. 

Maxine I. Collins, MBA, CPA, CMC, CMIS, CMOM, Instructor/Consultant for Practice Management Institute and CEO of M Collins & Co PLLC.