Warnings On The Use of EHRs - Medical Documentation

OIG warns on the use of the copy-paste function in EHRs

Medical Documentation Alert

• Risk adjustment
• Problems with incomplete documentation
• Medical necessity: Reasonable and necessary services
• E/M medical necessity
• OIG and Joint Commission's take on copy and paste
• Templates for ages and gender
• New and established patient documentation
• Examples of MDM and diagnosís

Although electronic health records are here to improve the quality in documentation , providers have to take steps  to avoid potential fraud. Providers are responsible for the input, vendors do NOT take responsibility or liability.

Vendors promote coding based on the diagnosis or data input for a patient encounter and that could be a fatal mistake for the provider. The provider is responsible for determining the level of service , medical necessity, and the quality of care. Furthermore, providers have been warned on the cloning of medical record from one patient to the next.

The HHS Office of Inspector General has issued a report on the degree to which users of electronic health records have policies addressing the use of the copy-paste function in EHRs and have implemented fraud safeguards. The copy-paste function in EHRs poses a substantial risk of fraud, according to OIG. Only 24% of providers or facilities that receive EHR meaningful use incentive payments had policies in place regarding use of copy-paste, and only 44% of providers/facilities audit logs recorded the method of data entry, which would flag copy-paste. The risk arises because providers may not update the copied information to ensure accuracy, and the function could be used to inflate claims and duplicate or create fraudulent claims. OIG recommended that CMS work with the Office of the National Coordinator for Health Information Technology (ONC) and the medical community to develop guidelines for using the copy-paste feature in EHR technology and consider whether the risks of some copy-paste practices outweigh their benefits. OIG recommended that CMS and ONC continue their collaborative efforts to develop a comprehensive plan to address fraud vulnerabilities in EHRs.

  

Ø  Does your documentation pass a Medicare or Medicaid Audit ?

Ø  Correct use of Level of Service billed?

Ø  Are you UPCODING or DOWN CODING?

Ø  Are the quality measures defined in the medical documentation ?

Providers are urged to implement procedures to audit the documentation in the medical record. Implement safeguards for level of service billed and/or  review the encounter to determine medical necessity.

For more details , contact:

SILBEN Healthcare Services, INC.

Paul G. Silverio-Benet

Phone: 305-975-1171

Email:  sbhealthcaremgmnt@gmail.com