Be Careful with the Copy and Paste Feature of Your EHR
By: Jason R. Miller, OD, MBA, FAAO
PECAA Member Since 2012
With many of us transitioning to EHR’s 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 our medical records. With CMS looking to recover a large amount of cash from Record Audits, it is important to take a proactive approach to improving our record keeping. As the saying goes, “the best defense can beat a good offense” and that is true with medical records. Knowledge is power and consider looking inside your medical records in 2014.
Specifically, we are going to discuss the “copy/paste” feature of many EHR’s. Other terms for this feature is “auto-populating”. It is a common feature and a nice selling point, but there is a time and place for the copy/paste. At least one of the Medicare carriers has termed the process of moving data forward from an earlier visit ‘cloning’, and has authorized its auditors freedom to expand their audits as soon as they suspect a physician is doing it. The 1997 Documentation Guidelines 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.
Is the information actually needed to meet the patient’s needs and the needs of the doctor managing the case?
Understand from an efficiency stand point, 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 bring some of it forward with any changes or a note: “no changes from previous exam dated ___________,” with Dr. initials. The key is that anything that is moved forward must be reviewed by the doctor and it must be germane to the visit; that is, actually needed to meet the patient’s needs and the needs of the doctor managing the case.
Along with the Reason for the Visit section, the Review of Systems (ROS) and Past Family Medical History (PFMH) can be top targets for auditors. These areas are easy to auto-populate, but may not be very important for the management of the case. In addition, they usually change slightly from year to year. Remember, all care needs to be driven by the patient’s needs and/or the needs of the doctor relative to the management of the case.
Information cannot be brought forward for the sole effort of improving the level of coding.
For example, we are not permitted to ask a bunch of questions to improve our level of case history. It is important to expand on the case history based on the reason for the visit and to provide better care. If we keep asking questions just to get to 4 questions in the history of present illnesses (HPI) for the sole reason of reaching an extended level of HPI and improve our coding level, that is not appropriate.
We record only what we actually did and choose the codes based on the content of the record. If you get through your exam and the EHR says you need 4 more elements in your HPI to code this encounter to the next level, be careful. At that point, your coding feature is driving what tests are being done, not the patient’s or doctor’s needs. If an auditor evaluates your medical records and finds the tests being done should not have been done or should not have been recorded, then they are going to assume they should not have paid you for that level of visit.
This feature has even hit the web. In an article on January 8, 2013, this topic was discussed. View Article.
The importance of medical record compliance…
A new study found that many doctors in an urban, academic medical ICU in Cleveland, Ohio were copying potential out-of-date information from previous medical records. Their study, which included 135 patient records, found that 82% of residents and 74% of attending physicians copied at least 20% of your previous medical record from a previous visit. In fact, there were some attending physicians who copied up to 82% 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 wrong information.
Medical record compliance is an important area to concentrate as Medicare is looking to recover as much as possible in overpayments. Medicare recovers billions from audits and abuse of the Medicare system. 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, choose them based on the contents of the medical record and be able to defend those choices.