Auto-populating + copy/paste = higher audit risk

April 10, 2013

Edited by Jason Miller, O.D., AOAExcel™ medical records and coding consultant

With the Centers for Medicare & Medicaid Services (CMS) looking to recover a large amount of cash from medical record audits, physicians need to take a proactive approach to improving record-keeping. With many optometrists transitioning to electronic health records (EHRs) in the past few years and many others looking to convert in the near future, it is important to take a step back and take a good look at the logic of medical records. Knowledge is power, and we encourage doctors and staff to look inside your medical records in 2013 to evaluate how your practice will stand up to a payer audit.

This article will focus on the “copy/paste” feature of many EHRs, also known as “auto-populating.” Auto-populating can be a nice selling point for EHR developers, and it can enhance the usefulness of medical records, as long as it is used appropriately. Be aware, though, that at least one of the Medicare carriers has termed the process “cloning” and has authorized its auditors to expand their audits any time they suspect a physician is auto-populating data. The 1997 Documentation Guidelines for the Evaluation & Management Services permit using data gathered at an earlier visit as long as the information is germane to the visit and as long as it’s clear the physician actually looked at the data that was moved forward.

Of course from an efficiency standpoint, these features can be very important when used correctly. It is all right to go back and review information from an earlier visit and even to bring some of it forward with any changes. Your record would include a note, such as “Reviewed ROS and PFSH from exam dated ___________, no changes except as noted” with the doctor’s initials or signature. The key is that anything moved forward must be reviewed by the doctor, and it must be germane to the visit, that is, actually necessary to meet the patient’s needs and the needs of the doctor managing the case.

Along with the reason for visit section, the review of systems (ROS) and past family social history (PFSH) can be top targets for auditors. These areas are easy to auto-populate with EHR, but some of the data moved forward may not be very important for the management of the case. In addition, the information in the ROS and PFSH may change from year to year. Remember, all the questions asked in the case history and all care provided to the patient must be driven by the patient’s needs and/or the needs of the doctor relative to the management of the case.

Information certainly would not be brought forward with the intent of raising the level of coding. On the other hand, it is important and perfectly appropriate to expand on the case history based on the reason for the visit and to provide better care.

The system will work great, either on paper or with EHRs, when doctor and staff record only what is done and choose the codes based on the content of the record. Some EHR systems will alert doctors or staff as to the number of elements recorded in each section of the record, possibly suggesting that completing four more elements in the HPI would “earn” a higher code for the visit. Never permit a coding feature in the EHR to determine the questions you are asking or the tests that are being done. The only determining factors, as we’ve emphasized throughout this article, must be the needs of the patient and the doctor’s needs. If auditors evaluate your medical records and believe the tests being done should not have been done or should not have been recorded, they are going to assume that the doctor/clinic should not have been paid for that level of visit.

Auto-populating has even hit the Web. In a Jan. 8, 2013, article, this topic was discussed at http://reut.rs/ZCdbJ2. A new study found many doctors in an urban, academic medical intensive care unit in Cleveland, Ohio, were copying potential out-of-date information from previous medical records. Their study, which included 135 patient records, found 82 percent of residents and 74 percent of attending physicians copied at least 20 percent of the previous medical record from a previous visit. In fact, there were some attending physicians who copied up to 82 percent of the previous chart forward.

Obviously some of this information may be harmless data and an excellent timesaver, but some of it may be completely outdated or unrelated to the current visit.

Medical record compliance is an important area to concentrate on as Medicare is looking to recover overpayments to physicians.

In fiscal 2012, Medicare recovered $6.9 billion from audits and abuse. Abuse is considered when a practice or individual causes, either directly or indirectly, unnecessary costs to the Medicare program. Some examples include misusing codes on a claim and billing for services that were not medically necessary.

Take a step back and look at which codes you are using, confirming that you choose them based on the contents of the medical record and that you will be able to defend those choices in an audit.

There are many resources out there to assist you in your record-keeping and coding. Check out www.aoacodingtoday.com and www.reimbursementplus.com.

As always, feel free to send your questions about this subject or other medical records and coding issues to askthecodingexperts@excelod.com. Ask the Codeheads is here to help you, 24/7, as a value-added benefit of membership in the AOA.

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