|
Part B News
May 1, 2006
“EMR & E/M: Beware of software’s potential to upcode”
Be careful that your electronic medical records (EMR) software doesn’t cause billing of E/M services at higher levels than your providers actually deliver. The potential of such upcoding has attracted the government’s attention, Part B News has learned.
You could face recipients, false claims allegations, and civil monetary penalties – even if you inadvertently upcode without any intent to commit fraud.
“Even if they’re not technologically savvy, providers can’t hide behind ignorance,” says health care attorney Abby Pendleton, Wachler & Associates, Royal Oak, Mich. During an audit, investigators could contend that through “reckless disregard” or “deliberate ignorance,” [providers] didn’t know but should have known they were submitting false claims, she adds. (See 5 steps you can take to avoid EMR coding mishaps on this page.)
The HHS Office of Inspector General (OIG) has drafted what appears to be a preliminary “National Medicare Fraud Alert,” which tops off federal and state government and law enforcement agencies to the “use of medical documentation software programs in a manner that results in the upcoding of Office Evaluation and Management Services.”
The document, obtained my Part B News, displays the HHS logo and the names of HHS and CMS, at the top. It appears to be an internal draft sent to various parties for review and feedback, and OIG spokesperson says. A CMS spokesperson was unable to comment.
Some software programs incorporate controls against upcoding, says Girish Kumar, president and co-founder of eClinicalWorks, Westborough, Mass. He says the eClinicalWorks EMR recommends codes, but does not prompt users on what additional items they need to record for a higher E/M code level. It also uses a template wizard that does not automatically default to the standard course of care for a particular diagnosis, so users “don’t blindly copy and paste items into the record,” Kumar says.
Signs of increased scrutiny
Last week, Medicare carrier First Coast Service Options warned providers in Connecticut that EMR software, by automatically filling in stored information from separate chart notes, may lead them to “over document” and consequently “select and bill for higher-level E/M codes than medically reasonable and necessary.”
Sue Bowen, director of coding policy and compliance at the American Health Information Management Institute (AHIMA) in Chicago, says she wouldn’t be surprised if Medicare scrutiny were heating up. Last year, AHIMA contracted with the HHS Office of the Coordinator for Health Information Technology to study automated coding and EMR’s role in health care fraud.
“I imagine the government would have looked to our recommendations,” she says, adding that federal law enforcement officials served on an AHIMA task force that produced the October 2005 report, which concluded that software should incorporate more fraud management controls, in light of national priorities both to reduce health care fraud and encourage the adoption of EMR Systems.
An earlier AHIMA task force had warned HHS that “Particular attention should be directed to the coding features of primary care EHRs [electronic health records] that prompt for evaluation and management code assignment.” –W. Vogenitz
5 steps to keep your software from cheating E/M trouble
EMR programs ease the burdens of data entry, but they could help document you into trouble if you use them without proper caution (PBN 3/27/06) (see story, pg. 5).
If your computer system isn’t set up properly, you could inadvertently follow “automatic pathways” toward improper coding and documentation, observes Scott Young MD, director for health information technology at HHS’s Agency for Healthcare Research & Quality. Here are five steps you can take to minimize these risks:
- Check your software’s default settings and remember to override them when they don’t apply to a particular patient or service. “An EMR won’t naturally put in things you didn’t do, unless you have them set as defaults,” Young says. “If you have a default that says, ‘I did a complete review of systems,’ that my be fine more of the time – but make sure you really do it’ and that your documentation supports it, he says.
Default settings could also present red flags to auditors, according to attorney Abby Pendleton, Wachler & Associates, Royal Oak, Mich. If the default doesn’t match the circumstances of an encounter, and recurs over a sample of charts, “one could argue that ‘key language’ was included simple in order to be paid at a higher level,” she says.
- Don’t be afraid to use templates, but don’t forget to individualize for each patient. Automated templates can help providers remember to report services provided. But when your electronic charts start to appear “cloned” – when patient e-records resemble each other or notes in a single patient’s chart look similar from visit to visit – an auditor may ask questions.
You can protect against medical necessity challenges by personalizing records as much as possible, including the reasons for a patient’s visit, changes from previous visits, test results – even a patient’s hobbies, suggests Robert Burleigh, president of Brandywine Healthcare Service, West Chester, Pa., and past president of the Healthcare Billing and Management assn (HBMA).
“If I pick 100 records to audit and every single chart looks the same, and ahs the same entries – for example, if only the patients’ heights, weights, and vital signs show real variation – I would suspect cloned documentation,” he says.
- Modify of delete template language when it doesn’t apply. If a physician typically performs full extremity exams, it’s reasonable to include this in a template, Burleigh says. But if an amputee comes in for a respiratory problem, don’t forget to remove that standard template ling. An isolated mistake may skate through, but you don’t want your records to show patterns of the same errors.
- Train everyone in your office who uses the EMR system, Pendleton suggests. For example, if your billing manager attends EMR training, but a physician who uses the system doesn’t, this could create problems if the physician inadvertently records information he or she doesn’t have or didn’t document. During an audit, investigators could argue the physician should have known better and question the lack of training, she says.
- Don’t let an EMR select codes for you. “An EMR can save you the trouble of looking up codes in the CPT book, but there is no product on the market that should be used without human intervention,” says Sue Bowen, director of coding policy and compliance at the American Health Information Management Institute (AHIMA) in Chicago.
Two potential pitfalls of the built-in coding options offered by many EMR programs: (1) the software could lead you to choices that are a leap from what your documentation supports or (2) you could use the product incorrectly and fail to review the code choices. “It’s still up to the provider of coder to evaluate a software product generates,” Bowen says. –W. Vogenitz |
