Use an EHR? Take caution with the cut-and-paste feature
Federal agencies issued warnings last month about using your electronic health record (EHR) to copy notes from a previous patient visit into current visit notes on a patient – especially if the earlier documentation involved a visit with another provider.
“A patient’s care information must be verified individually to ensure accuracy; it cannot be cut and pasted from a different record of the patient, which risks medical errors as well as overpayments,” said a cautionary letter to five health care organizations signed by Health and Human Services (HHS) Secretary Kathleen Sebelius and U.S. Attorney General Eric H. Holder, Jr.
The Office of the Inspector General indicated that in its work plan for 2012, it would be looking to identify “identical documentation across services.”
“When an agency such as the OIG targets something, we need to sit up and listen,” said Jeri Biedenkopf, R.N., ISMA practice advisor. “It’s important for physicians to review their charting procedures and have a mechanism in place that allows the best use of their EHR without cloning.”
Biedenkopf referred to an online Medscape article that urges physicians to carefully read and edit what appears on the EHR screen for accuracy. And an online article from the Journal of AHIMA (American Health Information Management Association) also discusses the risks of assorted EHR documentation shortcuts. (See links on right.)
In addition, Biedenkopf contacted WPS, Indiana’s new Medicare carrier, about the letter and work plan. Cari Dykstra, director, Outreach and Communications, advised, “WPS Medicare is aware of the issue concerning inappropriate use of EHRs. Through our educational programs, WPS provides guidance on the requirements for accurate medical record documentation to the medical communities that we serve. “
For more information
OIG work plan
Journal of AHIMA (American Health Information Management Association) article
From the OIG work plan…
Evaluation and Management Services—Potentially Inappropriate Payments in 2010
We will determine the extent to which CMS made potentially inappropriate payments for E/M services in 2010 and the consistency of E/M medical review determinations. We will also review multiple E/M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments. Medicare contractors have noted an increased frequency of medical records with identical documentation across services. Medicare requires providers to select the code for the service on the basis of the content of the service and have documentation to support the level of service reported.
(CMS’s Medicare Claims Processing Manual, Pub. No. 100-04, ch. 12, § 30.6.1.) (OEI; 04-10-00181; 04-10-00182; expected issue date: FY 2013; work in progress)
Medicare 'high dollar claims' require additional info
Wisconsin Physicians Service Insurance Corporation (WPS) Medicare Part B instituted editing for high dollar claims beginning with dates of service Oct. 1, 2012, and after.
The Office of the Inspector General has performed audits on multiple contractors and found that payment for these high dollar claims has not been appropriate. As part of the transition process, WPS has not been adjudicating claims from Indiana providers for these high dollar claims.
Effective Oct. 1, 2012, WPS began requesting additional documentation for all claims considered high dollar, a line item that meets a threshold of $7,500 or more. WPS will evaluate information on the claim and send a development letter asking for additional documentation.
WPS has information on its website concerning the most common errors (physician signature missing, dosage of drug missing, order for drug missing). You can also find several articles under the claims processing web page on the WPS website.