Document and code in an EHR with care

September 25, 2012
Maxine Lewis, CMM, CPC, CPC-I, CCS-P

This month's question asks how to document and code in an EHR. Find out the answer to this pressing coding question.

A: able to document a patient's visit with the assistance of an EHR, all documentation must be medically indicated for a patient's presenting problem.

For an established patient, only two of the three key components (history, examination, and medical decision-making) must be used to select a level of service. With a simple click, you can upload the history portion-consisting of the review of systems and the past, social, and/or family history. You still must note and update the chief complaint and history of present illness if a disease is chronic.

In addition, auditors have seen cases in which the physical examination has been brought forward to the new encounter, sometimes without changes. EHR templates are standard for all patients, so you may not be able to distinguish one patient's physical examination from another.

Also, the question arises from having so much documentation available: Is the documentation medically indicated for the patient's presenting problem? The federal government also sees this can be a problem.

Let's assess the extent to which the Centers for Medicare and Medicaid Services (CMS) made potentially inappropriate payments for evaluation and management (E/M) services and the consistency of E/M medical review determinations.

Medicare contractors are noting an increased frequency of medical records with identical documentation across services. Medicare requires you to select the code for the service you provide based on the content of the service and that you have documentation to support the level of service you report.

Medical decision-making should drive what should be and is appropriate for the patient. The documented work not only should include the key components, but also must be reasonable and necessary. Many of the EHRs currently available include in the medical decision-making portion helpful templates for specific diseases and treatment plans.

A significant problem occurs, however, when an EHR automatically posts a code to a patient's bill when no provider has been selected and the level of service is taken from the encounter.

You are responsible for ensuring that the codes you submit accurately reflect the services you provide. E/M codes represent the type, setting, and complexity of services provided, as well as the patient's status (new or established).

CMS analyzes the E/M codes by specialty and uses data-mining to determine the names of outliers (doctors who report codes more frequently or at a higher level than their specialty peers). Recovery audit contractors use this method in their searches for overpayment.

The physician whose name appears on the claim for the third-party payer, not the EHR software, ultimately is responsible for the code reported.

The author is president of Medical Coding & Reimbursement in Cincinnati, Ohio.