Medicare is encouraging the implementation and use of electronic health records, but the way some practitioners fill out these records is under scrutiny. The U.S. Department of Health and Human Services Office of Inspector General has made cloning (inappropriate use of the copy-paste feature) and over-documentation areas of high priority for 2014.
OIG has recommended that the Centers for Medicare and Medicaid Services evaluate EHRs for fraud vulnerabilities. If fraud is suspected, practices will be subject to fines and penalties. It is essential that audiologists use EHRs effectively and not take too many shortcuts. As we transition from paper charts to EHRs, here are a few things to know.
1.) Review all entries in your note. Avoid repeating past information.
According to CMS 1995 and 1997 documentation guidelines, “A review of systems and/or a past medical, family, and social history obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician [audiologist] reviewed and updated the previous information.” In other words, in your note, refer to a previous note that has the comprehensive history. For example, you could write, “See note dated 1/1/2014 for a comprehensive history of patient X,” and update the present concerns/reason for the visit.
2.) Make sure all your diagnoses listed are relevant for that patient’s visit.
Many EHR systems allow the copying of all diagnoses listed in the problem list, even those that have been resolved or aren’t the reason for that day’s patient visit. Be sure to only list the diagnoses that are relevant for the reason the patient is seeing you. For audiologists, the first diagnoses code should be your treating diagnosis followed by the relevant medical diagnoses. Sometimes the treating and the medical diagnoses are the same and there is only one listed.
3.) Make sure your note is individualized for that patient’s encounter.
Many EHR systems also allow you to clone a previous note. Use extreme caution with this feature. Auditors are looking for patterns in documentation. If all your notes look essentially the same across time and across the patients you serve, then they will cite you for not providing individualized care. Review every item in your note to make sure they are relevant for that patient’s visit that day.
4.) All notes should be signed by the licensed professional, correctly dated for when the services were rendered, and the time associated with the visit.
Lawyers, auditors and accreditation organizations look when the notes are completed. All notes should be started on the day services were rendered and finished within 24 hours. The note should have not only the signature of the provider but the time and date on the note. If your notes are not completed in a timely manner, then be prepared to answer, “What are you trying to hide?” or, “How many patients did you see that day? How could you remember what to write if you did your note a week later?” Any notes that are placed in the medical chart greater than 24 hours after the patient was seen is subject to concern.
5.) Avoid saving the note on the wrong date—a common mistake when a professional does not complete documentation on the day of service.
Two things to know:
- If the note is not there on the day of service, then the patient was not seen.
- If you dropped charges on a day of services that the patient did not have an appointment and was not seen, then this is considered fraudulent billing and you could be subject to not only losing your license to practice but also significant fines. If this happens, amend the note immediately to the correct day of service! To prevent this from happening, try to incorporate your documentation during the day or at “bedside” when you are with the patient.
6.) Develop a policy on the use of cloning, the copy-paste feature, and over-documentation in EHR technology. CMS has been charged with reviewing your policy if your site is selected for audit. OIG reported that only a third of practices audited had a policy. Be prepared!
Documentation should not be considered additional work but an extension to your patient care activities. Finally, remember our ultimate goal is to provide the best possible care that is timely and based on evidence-based practices. Having timely and accurate information in your note, and nothing else, will help provide the best possible care to your patients. The consequences are too serious to do anything less.
For additional information about documentation, visit leancare.wordpress.com.
Tamala Selke Bradham, PhD, CCC-A, is associate director of quality, protocols, and risk management in the Department of Hearing and Speech Sciences at Vanderbilt University. She is an affiliate of ASHA Special Interest Group 9, Hearing and Hearing Disorders in Childhood.