E/M Auditing in the EHRPresented by: Paula Kleiman, RHIA, CPC, AHIMA ICD-10-CM Trainer

CEO/President, Creatively HIM Consulting Services, Inc.

Objectives

• Risk and Regulatory Compliance

• EHR Benefits

• Establish an effective Compliance Auditing Program

• EHR auditing each Evaluation and Management (E/M) components

History

Physical Exam

Medical Decision Making (MDM)

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E/M Codes Under Scrutiny

• Evaluation and Management codes drive most of the revenue in a physician practice

• Increased complex government legislation, regulatory compliance, and fraud investigations

• Questions to ask:

• Does the documentation truly justify the services rendered

• Are the services medically necessary for the diagnoses treated?

• Payers utilize data analysis to identify outliers i.e., physicians billing at higher than normal levels

• External auditors include: Medicare Administrative Contractors (MACS), Zone Program Integrity Contractors (ZPICS), and Recovery Audit Contractors (RACS)

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2014 OIG Workplan

• Coding of Evaluation and Management Services — the OIG will review evaluation and management claims to determine whether coding patterns vary by provider type. Medicare contractors have seen an increased frequency of medical records with identical documentation across services as well as increased frequency in providers’ responsibility to select the code for the service based upon the content of the service and maintain documentation that supports the level of service reported. The OIG plans to review the extent of potentially inappropriate payments for evaluation and management services. This is a particularly significant issue for practices using electronic medical records. Providers should be diligent in documenting the service — particularly the examination — that is appropriate to the problem being addressed

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2015 OIG Workplan

Per AAPC “What Isn’t in This Year’s Plan”

• While many familiar areas remain as a focus in this year’s workplan, the traditional scrutiny of physician evaluation and management (E/M) service reporting seems to have slipped from sight. Although an absent area in the work plan, providers should not expect Medicare program safeguard contractors (PSCs), zone program integrity contractors (ZPICs), and recovery audit contractors (RACs) to ignore E/M reporting as an audit issue.

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EMR Benefits

• Easy access to patient information from anywhere

• Improved coordination of care

• Automated formulary checks by health plans

• Order and receipt of lab tests and diagnostic images

• Links to public health systems such as registries and communicable disease databases

• Increased efficiency

Variations of provider documentation options

Rx, Order, Charge modules

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EMR Challenges

• Security of electronic data

• Emergency Preparedness and Response

• Copy and Paste

• Templates

• Other documentation methods i.e., citation of entire ancillary reports into the progress note

• Each note should stand alone and reflect what happened with the patient during the encounter/service date

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Copy and Paste Documentation

• Electronic health records (EHR) often include tools and functions designed to increase efficiency (e.g., the ability to copy and paste information from previous encounters). However, these tools and functions may also leave physicians vulnerable to compliance risk.

• Watch for pre-populating body systems as “normal” in the EHR unless a physician uncheck that they did not review that particular body system. This could result in higher-level E/M codes that aren't justified.

• Create a policy regarding copy-and-paste functionality; work with your EHR vendor and physicians to help them understand the copy-and paste function

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Auditing Pre-Requisites

• EHR functionality

• Variations in data location

• Policies and Procedures

• Guidelines utilized

• Entering data workflows

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Auditing Program

• Auditing Program Policies and Procedures Determine Frequency of Audit

Choose chart sampling selection

Establish Coding Quality Benchmarks/Thresholds

Reporting Results

Training Follow Up

• Audit Tools/Worksheets

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Chief Complaint

• Required to establish medical necessity

• May be inferred in the History of Present Illness (HPI)

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History of Present Illness (HPI)

• Who documented the HPI• Use documentation Audit Trail logs • Phrases in question• Copy-n-Paste• In doubt, don’t count

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Review of Systems (ROS) and Past, Family, and Social History (PFSH)

• Can be updated by ancillary staff

• Documentation should indicate source

• ROS forms completed by patients

• Copy-n-Paste, or brought forward

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Physical Exam (PE)

• Templates

Condition / injury specific

Level based

• Copy-n-Paste, pull forward

Must update

• Look for conflicting information

• In doubt, don’t count

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The link between Medical Necessity and the Presenting Problem

• Does the documentation support the diagnoses

• Does the physical exam and review of systems justify the presenting problem (e.g., a comprehensive exam performed for a simple problem like earache)

• An external auditor may question the level of service as inappropriate based on the nature of the presenting problem

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Medical Decision Making (MDM)

• Diagnosis selection

Drop down list

Check boxes

Pulled from problem list

Favorites list

• History and exam must support each diagnosis

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MDM

• Data Review of test Interpretation of testing / Independent visualizationOrders

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MDM

• Risk / PlanPresenting problemsDiagnostic procedure(s) orderedManagement options

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Summarize E/M Findings

• Create a summary report for your physicians with the E/M findings and conclusions

• Present the findings to the physicians on a regular basis (monthly, quarterly) Help them to understand documentation deficiencies and/or usage of EHR

• Trend data – look for outliers

• Implement corrective action plan

• Share findings with key stakeholders

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Conclusion

• Time saving features are attractive and can still be beneficial

• Auditing can identify short comings

• Establish Policies and Procedures, and guidelines to support compliance

• Customize EHR’s systems to overcome shortcomings

• Conduct Training

• Determining areas of risk in your organization, including them in your compliance and auditing plan and managing corrective action will steer you away from external scrutiny.

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Questions?Please contact us at pkleiman@creativelyhim.com

Thank you.