EHR Document Errors
EHR Document Errors Have Caught the Interest of the OIG
You can lower payer audit risk and rejections that are related to insufficient documentation in your electronic health records (EHR) with routine audits that verify who entered the patient information, notes that are distinctive or errors that have been amended.
Documentation of EHR mistakes has captured the attention of the Office of Inspector General (OIG). According to a PartB News article on 10.29.12, from 2009-2011, E/M denials have hovered between 4%-6% for established patients and 9%-10% for new patients. This has prompted the OIG to begin looking at electronic health records of evaluation and management documentation beginning from 2010 for inappropriate payments that result from cloned notes or the same documentation from different patient's record.
Begin Auditing EHR records in these two areas:
User integrity
It's important to know who started the documentation, because a user ID does not let you know which provider ordered a procedure or test due to password sharing.
- User accounts should be set up with different levels of permission and authority that will control who has permission to perform particular functions within the EHR. For instance, medical assistant should not have the ability to alter physician notes or diagnosis, but should be allowed to document things such as patient s immunizations.
- It's important to use your EHR's audit trail to trace your staff access patterns. That function can be used to observe who changed records and to make certain that the staff access only portions of the patient records significant to their job responsibilities.
- Observe documentation for future visits with patient history from 2011 filled in for 2012. For example a patient blood pressure may fluctuate each week, but the record will have the same blood pressure for each visit which will look suspicious to an auditor.
- When you see errors in the medical records make sure to correct them on the spot. If a patient was billed for a procedure or service that they said was not done, make sure to check that the record is correct and look into the complaint. You do not want the patient to call Medicare administrative contractor (MAC) to handle the problem because this can bring on an audit.
- You should have a designated person to do regular audits of EHR user accounts to ensure that they have access only to areas that relate to their specific duties; which means non-clinicians should not be able to access or amend any patient records. Keeping the numbers of users down to who needs access to the records can avoid any confusion.
- Providers should avoid signing documents without reading it. At times providers will automatically sign documents in EHR just to clear the queue which can lead to problems if records are not read. To avoid this, make sure each provider uses a distinctive signature pin that is not shared; this will force the provider to go into the record and approve it rather then simply clearing the queue.
- Keep an audit of your EHR to ensure that entered information is accurate because medical records are considered binding statement which confirms that all procedures, services, coding and documentation were completed. If the information is incorrect it can by used by the OIG in an audit even if the EHR system is the cause of the error such as with cloned progress notes. It is the responsibility of the provider to correct. If an audit occurs you cannot blame the vendor, because they will deny that it s not their responsibility for medical record accuracy.
The US Department
of Health and Human Services (HHS) has mandated the replacement of the ICD-9-CM
code sets used by medical coders and billers to report health care diagnoses and
procedures with ICD-10 codes, effective Oct. 1, 2014. ICD-10 implementation will
radically change the way coding is currently done and will require a significant
effort to implement. The time for