p-spencerWe find ourselves at the dawn of the era of the mandatory electronic medical record (EMR). While the technology holds the promise of simplicity of integration and coordination of care, I am beginning to see that creating a medical record that makes sense to an auditor may become a longer road than physicians are anticipating.

In my role as a physician documentation auditor, I am learning that the term “meaningful use” is applicable more to an oblique government standard and not so much to documentation of a patient’s actual illness. This year I have conducted documentation reviews for physicians in clinical and hospital settings that have proven this thesis in bold and uncomfortable terms.

In one case I had a physician who, as part of the examination template, utilized the term “average stature” on every sample submitted for review. The patients reviewed in this case ranged from a 140-pound female to a 397-pound male, which by any measurement would reflect a rather inclusive definition of the word “average.” In another case we had a hospital-based physician group that was utilizing an EMR for their particular patient base. In more than one case, specific laboratory test results were indicated as “pending” several days after the desired result was noted in the medical record.

Both of these examples point to the biggest problem with EMR implementation, which is best summarized as “build what makes you comfortable.” When training physicians to utilize a new EMR, adequate time to prepare them for its best use too often simply isn’t available. To combat the time crunch, the trainer, in concert with the physician, typically assists in building a patient encounter template that represents the most likely patient to be encountered rather than a model with the ability to be adjusted based on the presenting symptoms of the patient.

This problem is exacerbated by coding consultants who are quick to offer “phrases that pay” and are far too slow in counseling physicians about documentation and code selection focused on medical necessity. This leads to language in examination documentation that is in opposition to itself from paragraph to paragraph, and more importantly information that doesn’t provide a clear picture of the patient’s actual health status. What at first appears to be a well-organized EMR template built for physician simplicity quickly morphs into the appearance of “cloned” documentation built to describe many patients – which in turns increases audit risk.

With regard to physician documentation, the recovery auditors thus far have focused their attention on plans of care created by admitting physicians in the hospital setting. As a result, hospitals in turn have turned to clinical documentation improvement (CDI) to remedy shortcomings identified by the auditors. One wonders whether the timing of CDI programs is accidentally premature given that newly implemented EMRs have the potential to reopen Pandora’s Box as hospitals acquire physician practices in advance of the Accountable Care Organization model.

Physicians in private practice have yet to feel the full force of recovery audit efforts to find improper documentation, and CMS has stated in the past that it will alert physicians nationwide when evaluation and management services are about to be audited. There is a significant difference with this population of doctors, however, as they tend to exist without a training infrastructure to assist them in fine-tuning their electronic documentation. A great many physicians not affiliated with large institutions find themselves at the mercy of either their office staff or outside consultants of varying quality, many of whom do not exhibit minimal emotional investment in the physician’s best interests.

The proliferation of EMR systems can be seen as a chance either to seize or be seized by opportunity. Choosing a specific electronic medical record for your practice should not be seen as a simple way to make a quick buck. In selecting an EMR for implementation, physicians should do their best to block out the voice of the salesman promising thousands of dollars in meaningful use dollars and instead select an EMR that will allow for flexibility based on the range of patients seen by the practice. Any and all vendors should be quizzed carefully about training expectations and end benefit to your practice. In addition, physicians should embrace a mindset that learning how to use your EMR never ends. This would be very similar to recovery auditors remaining dedicated to their never-ending quest to seek out improper payments based on deficient documentation.

About the Author

Paul Spencer is the Compliance Officer for Fi-Med Management, Inc., a national physician practice financial management company based in Wauwatosa, WI. Paul has over 20 years of experience across all facets of healthcare billing, including 6 years spent with insurance carriers. In his current role with Fi-Med, he acts as a physician educator on issues related to E/M level of service and documentation audits by CMS and other outside entities. Paul has carried the CPC and CPC-H credentials from the American Academy of Professional Coders since 1998.

Contact the Author


To comment on this article please go to editor@racmonitor.com

Using Data Mining as a Component of Audit Defense

Share This Article