EHR documentation: Avoid note cloning and up-coding

Renee DowlingQ: We are using an electronic health record (EHR) system for our clinical documentation. Are we putting our providers at risk because there are so many ways to misuse it?

A: If you’ve ever been involved in the sales pitch or training for an electronic health record (EHR), you know that they focus on ways the system can cut down on the time a practitioner needs to document the patient record.

These include short cuts such as templates and sets of information that can be inserted at the touch of a button, copying information verbatim from your own note or another provider’s note, and pulling an entire note into your patient visit. While these are great time-savers, they might cost you in the long run if they are misused.

According to the Centers for Medicare and Medicaid Services (CMS), the cost of healthcare fraud is estimated to be between $75 billion and $250 billion. Additionally, experts in health information technology caution that EHR technology can make it easier to commit fraud. The Office of Inspector General has listened to these experts and made EHR cloning and over-documentation a top priority in 2014. 

Here’s more detail regarding these two areas:

Copy-and-paste

Copy-and-pasting, also known as cloning, allows a user to select information from one source and paste it to another location.

When clinical staff members (i.e., physicians, non-physician practitioners, nurses and other clinicians) clone information but fail to update it or ensure its accuracy, inaccurate information may be placed in the patient’s medical record and inappropriate charges may be billed to payers and/or patients. Also, inappropriate cloning could facilitate attempts to increase the information and create fraudulent claims.

Up-coding

This is the practice of inserting false or irrelevant documentation to create the appearance of supporting a higher level of service. Some EHRs auto-populate fields when using templates built into the system.  Other systems generate extensive documentation on the basis of a single click of a checkbox, that, if not appropriately edited by the physican, may be inaccurate. 

This can produce information suggesting that the practitioner performed more comprehensive services than were actually billed.

Use caution

While it is easy to get caught up in using these shortcut features, be careful when doing so.

If you use them, be sure to review and update the information to reflect the any changes in the patient’s history or condition-and your work-specific to that day’s visit.  EHR’s have an audit trail that shows what and when you and your clinical staff have touched the patient record. 

The answer to the reader’s question was provided by Renee Dowling, a billing and coding consultant with VEI Consulting Services in Indianapolis, Indiana. Send your coding and billing questions to medec@advanstar.com.