Evaluation and Management Services and the Electronic Health Record

Electronic Health Record (EHR) Incentive Programs are having a big impact on provider documentation.  Medicare and Medicaid EHR Incentive Programs provide incentive payments to eligible professionals, and eligible hospitals and critical access hospitals (CAHs) as they adopt, implement, upgrade, or demonstrate meaningful use of certified EHR technology. As a result, more providers are utilizing electronic medical records (EMR) to document patient encounters, specifically evaluation and management (E/M) visits.

Templates: Benefits and Risks
There are many benefits of an EHR, particularly the ability to use a template to assist with documentation. Templates allow the provider to customize common information that occurs during patient visits. This standardization of documentation helps ensure that components of the history and exam are captured. The ultimate goal of an EHR is to increase efficiency and accuracy in patient documentation.
However, there are some difficulties with EHR documentation. Many EHR fields are auto-populated, meaning the field is pre-populated with the usual clinical finding. If the patient does not fit this description, then the provider must change it. Without proper training and monitoring, documentation is prone to errors and inconsistencies. 

Office of Inspector General (OIG)
Every year the Office of Inspector General releases a work plan for new and ongoing audit and enforcement priorities. Reviewing the work plan each year is important as it assists with identifying compliance risk areas. The Fiscal Year (FY) 2012 OIG Work Plan identifies EHR documentation as an area of potential risk.

From the FY 2012 OIG Work Plan:
Evaluation and Management Services: Potentially Inappropriate Payments
We will assess the extent to which CMS made potentially inappropriate payments for E/M services and the consistency of E/M medical review determinations. We will also review multiple E/M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments. Medicare contractors have noted an increased frequency of medical records with identical documentation across services. Medicare requires providers to select the code for the service based upon the content of the service and have documentation to support the level of service reported. (CMS's Medicare Claims Processing Manual, Pub. No. 100-04, Ch. 12, § 30.6.1.) (OEI; 04-10-00181; 04-10-00182; expected issue date: FY 2013; work in progress)

As mentioned above, it is important that the documentation remains consistent throughout the entire visit. For example, a patient presents to his or her physician's office for evaluation of a rash. If the history and or examination provide conflicting information, then the validity of the content for that visit could be questioned if reviewed by an outside source.

Medical Necessity Presides in Determining Level of Service
While EHR templates make it easy to capture components of the history and exam, remember that the level of service is always determined by medical necessity. As indicated in section 30.6.1 of the Medicare Claims Processing Manual, Chapter 12:

Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.

In summary, documentation should be limited to what is medically necessary for that encounter. If a patient presents for follow-up evaluation of knee pain, it would not be medically necessary for the provider to examine the patient's pupils and external ears and nose without any clinical indication. The patient's knee pain clearly does not warrant an examination of the eyes, ears, and nose.

How to Protect Your Provider and Practice
In order to protect your provider and practice, periodically review documentation for inconsistencies and content that is irrelevant or unrelated to what was clinically indicated for that visit. Communicate any findings to the provider and the individuals who oversee the organization's EHR program so additional training can be provided if necessary. An EHR can be a beneficial tool for documentation; however, inconsistencies can pose a big risk to the provider and the organization.

Resources: https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/EHRIncentivePrograms/

Amy Bishard's career in the healthcare industry began in 1999, working part-time in a clinic's business office. After completing college, she pursued a career in medical coding and obtained her CPC®. As a clinical coding auditor and educator at CoxHealth, Amy monitors Medicare regulations and works with recovery audit contractor (RAC) audits. She designs and delivers educational presentations for physicians and coding and billing staff. Amy develops curricular materials for her chapter's review classes, as well; and she enjoys mentoring new members and networking with other coders. She is currently a member of the AAPC Chapter Association (AAPCCA). (www.aapc.com)