Extra Care Needed in Use of Prepopulated EHR Templates
The widespread use of electronic health records (EHR) has led to the use of templates by many physicians. Some of these include prepopulated or “normal” physical exam templates that enter information into the patient’s record assuming normal details of the exam performed. This can be extraordinarily problematic because the practice requires what I call a “negative action” on your part to ensure accurate chart documentation. You need to go through that imported exam to un-check, delete or change any parts of the exam that were not normal. If you forget to do this, the exam documentation may be in conflict with the chief complaint, history of present illness, or the assessment and plan. In the event of an audit the service for which you billed will be declined.
Insurers have indicated that inserting information that assumes entire sections of the record as being “normal” is not an indication that the work has been done. Phrases such as falsification of medical records, misrepresentation, and clinical plagiarism indicate the insurance companies are developing policies that will result in negative outcomes for someone who does not provide original documentation on a patient for a specific visit and date of service. Reed Gelzer, MD, MPH, co-founder of the Advocates for Documentation Integrity and Compliance, stated it best when he said, “Overwriting (cloning) misrepresents who provided the service, which could alter the amount billed. In addition, by submitting cloned documents for billing you are committing (insurance) fraud.”
So what does this mean for your exam? Document what you do. If you see a patient for a minor problem and the level of service for that office visit is 99213, you are required under 1995 Evaluation and Management (E&M) guidelines to only document two exam elements. That is not to say that you cannot document more, but from a documentation perspective you need only two. A 99214 generally requires five exam elements. Instead of importing a cloned or “normal” physical exam on the patient, simply document what you examine. In using your normal physical exam, which may include information about 12 organ systems, what did you find medically necessary to examine for that patient? Documenting exam elements of skin, gastrointestinal and genitourinary for someone with an ear ache may not be necessary. Even the 99214 service, which might be for an older patient who has several co-morbidities affecting your medical decision making about the ear ache, requires only five exam elements (i.e. ENT, eyes, heart, lungs, constitution). It is more efficient, accurate and compliant to document those five elements instead of 12 in your cloned document.
The next time you have a complicated patient, measure how much time you spend reading through your “normal” template to make sure it represents the patient’s actual exam. Not only will you find it more efficient to document what you examine, it is the compliant and audit-passing way to document. Know the required documentation of the exam for the E&M code selected and document those items. You can add more if you feel it is necessary. Please understand, I am not telling you as a physician what you cannot do. I am simply suggesting that if you know the required exam elements, you may find importing and correcting documentation of the 12-element “normal” exam does not make you more efficient or compliant. With so many things taking up your time, anything that saves you a few minutes that can be shifted to patient care is invaluable!