As physicians become more comfortable with EHRs and see their benefits for patients (including an up-to-date record with full history a mouse-click away to any provider in a health system), they are increasingly interested in best practices related to upcoding and cut and paste. In-depth advice on the former was released earlier this year by The Partnership for Health IT Patient Safety, a collaborative convened by the ECRI Institute, a nonprofit seeking ways to improve patient care.
In March, the partnership released a series of evidence-based recommendations along with a free toolkit with educational materials, checklists, and assessments. The recommendations are:
- Provide a mechanism to make copy and paste material easily identifiable.
- Ensure that the provenance of copy and paste material is readily available.
- Ensure adequate staff training and education regarding the appropriate and safe use of copy and paste.
- Ensure that copy and paste practices are regularly monitored, measured, and assessed.
In October, Lorraine Possanza and Robert Giannini of ECRI told attendees at AHIMA’s annual conference that vigilance is necessary to prevent the copy/paste function from causing physicians to doubt the validity of patient records. “If I pasted information and it’s incorrect and I repeatedly paste that information that is incorrect, I now have errors that are propagated,” said Possanza. The presenters pointed out that copy/paste can also contribute to note bloat, notes that become overwhelming in length with redundant information, which could lead to diagnostic error.
What do auditors watch for?
Upcoding was the other hot EHR-related topic at the AHIMA conference. Kim Garner Huey, a coding and reimbursement consultant, and Sandra Giangreco, a coding compliance senior manager with CHAN Healthcare Auditors, told their audience that CMS is more concerned than ever about overcoding.
Garner Huey said auditors are especially interested in the following when examining EHR documentation:
- Contradictions between history of present illness and review of systems
- Wording anomalies or grammatical errors that could indicate “something other than above-board clinical notes”
- Medically implausible documentation
- Issues related to signatures, dates, and times
The presenters advised practitioners to thoroughly understand all code generators and templates being used. Ask:
- Is the software programmed to account for policies specific to your local Medicare contractor?
- How does the coding tool manage dictated portions of the encounter?
- How does the coding tool distinguish between different levels of medical decisionmaking?
- Are providers able to choose only part of a template or to personalize one?
- Are there multiple templates for compliant or diagnosis?
- Are contributors to the encounter (e.g., nursing staff and physician) identified in the record?
As EHRs evolve and physicians recognize their importance to coordinated patient care, coding and charting best practices must become an integral part of office culture to allow everyone to reap their full benefits.