Mildred L. Johnson, JD, CPC - Health Care Compliance Association

matter experts to develop suitable guidelines to
prevent fraud in electronic health record documentation.
The participants included fraud
investigators, physicians, attorneys, information
technology specialists, health information
management professionals, coding and
reimbursement specialists, compliance officers,
audit managers, and technology vendors. The
work group produced a set of guidelines (available
at http://library.ahima.org/xpedio/groups/
public/documents/ahima/bok1_033097.
hcsp?dDocName=bok1_033097), an EHR
fraud checklist, and three case studies that are
helpful for compliance education and discussion
starters.
The identified areas of concern regarding
some EHR environments centered around
the following functions:
n Authorship integrity
n Auditing integrity
n Documentation integrity, and
n Patient identification and demographic
accuracy
Avoiding the path towards dirty data
Health records are generally a composite of
observations made by physicians, nurses, pharmacists,
therapists, social workers and others
who record the interventions made while
providing patient care services. All these clinicians
have a role in data quality and document
completeness. It is important for the record
data set to reflect who is responsible for the
entries made. Any EHR features or tools that
allow unrestricted changes to released documents,
or allow authors or others to change or
eradicate the work documentation, must be
prohibited or carefully controlled.
Determining who is responsible for providing
services is a concern in both a paper chart
environment and its electronic replacement.
One method of healthcare fraud includes
using unlicensed or otherwise unqualified
individuals to perform services while submitting
claims under the provider number of a
legitimate practitioner.
Another authorship and documentation
integrity issue that is well known to the compliance
profession involves academic medical
centers and Medicare payments. Teaching
institutions must provide evidence pursuant
to 42 CFR 415.172 (b) that the documentation
must identify, at a minimum, the service
furnished, the participation of the teaching
physician in providing the service, and
whether the teaching physician was physically
present. Students may document services,
but for evaluation and management (E&M),
the documentation is limited to review of
systems and/or past family/social history. The
teaching physician should not copy and paste
student documentation of physical exam findings
or medical decision making into their
own notes. If a medical student documents
E&M, the teaching physician must verify and
re-document the history of present illness as
well as perform and re-document the physical
exam and medical decision making.
Tool time
Documentation tools, such as templates and
other forms of automated text production,
must be used with care. Appropriate safeguard
policies, best practices, or the assistance
of software functionality must be applied to
prevent degradation of data quality.
Computer-generated “macros” are acceptable
for shortening data input for busy clinicians;
however, their use should be monitored to
make sure the results accurately represent the
services provided and will not compromise the
integrity of the record in court. To ensure that
the record meets legal requirements, appropriate
audit trails are required in electronic systems
to track changes made in documentation
and to preserve the integrity of the content.
Auto-authentication means that a physician
or other authorizing person in an electronic
health record environment signs multiple
documents at one time without opening
them. With auto-authentication, judicious
review for accuracy falls short of federal and
state authentication requirements and this
could place the organization at legal risk
when accuracy of the record and its ability to
serve as a legal document are required. 5,6,7
Thou shalt not steal
“Borrowing” data from other sources (where
copy-and-paste or “pull forward” techniques
are used) must be carefully monitored,
particularly when this involves E&M service
coding for reimbursement. The resulting
billing codes are based on work intensity elements
and the expectation that the documentation
correctly reflects the service rendered
at the encounter in question. For example,
when a patient comes to a physician office
with a new problem, the physician is expected
to perform a complete review and update
of the family and social history, a history of
the present illness, and a current review of
systems. This is followed by a physical exam
appropriate to the chief complaint, and then
medical decisions are made. Finally, a plan of
care is developed. If a physician were to “pull
forward” the history elements from the initial
visit into a subsequent follow-up visit, there
is a risk that the E&M may include elements
that were not provided during the second
encounter. It would be inappropriate to consider
the history review in the level of service,
despite the fact that the physician note makes
it appear that the history elements were
repeated at the subsequent visit and should
be a factor in the service intensity level. E&M
calculation software tools must also be used
with care to assure that any documentation
generated reflects services actually provided at
the level represented.
Continued on page
Health Care Compliance Association • 888-580-8373 • www.hcca-info.org
February 2007