Scribing in an Electronic Medical Record - ascrs 2012

Scribing in anElectronic Medical RecordFinancial DisclosureThe instructor is a consultant for CorcoranConsulting Group and acknowledges a financialinterest in the subject matter of this presentation.Donna M. McCune, CCS-P, COEVice PresidentCorcoran Consulting GroupPurpose• Identify best practices• Avoid potential problems• Suggest how to upgrade your EMRDocumentation and Correct CodingGeneral Principles• The medical record should be complete and legible• Each patient encounter should include:• Reason for encounter and relevant history• Physical examination findings• Prior diagnostic test results• Assessment, clinical impression or diagnosis• Date and legible identity of the observerSource: Evaluation and Management Services DocumentationGuidelines – AMA and CMSDocumentation About Scribes• Physician’s notes• Affirmation of presence, accuracy, corroboration• Scribe’s notes• Identity of scribe, physician, patient• Date of serviceSource: NGS, Sept. 15, 2010www.nacmed.org/bulletinboard/medicare-updates/documentation-requirements-when-scribes-areutilizedTarget for ScrutinyE/M: Potentially Inappropriate Payments“We will assess the extent to which CMS made potentiallyinappropriate payments for E/M services and the consistency ofE/M medical review determinations. We will also review multipleE/M services for the same providers and beneficiaries to identifyelectronic health records (EHR) documentation practicesassociated with potentially ti improper payments. Medicarecontractors have noted an increased frequency of medicalrecords with identical documentation across services. Medicarerequires providers to select the code for the service based uponthe content of the service and have documentation to supportthe level of service reported.”Source: HHS OIG FY 2012 Work PlanCorcoran Consulting Group (800) 399-6565 www.corcoranccg.com

Best PracticesChief Complaint• Obtain a useful chief complaint (CC)• Justifies your reimbursement from the payer• In the patient’s own words• Identifies the reason for visitit• Blurred visionSymptom• Itch, burn, redSymptom• Difficulty seeing signs while driving Symptom / ADL• Uncontrolled DM – R/O DRSystemic disease• 3 month glaucoma check as directed Chronic diseasePotential ProblemsChief Complaint• Use caution:• CC posted the day prior to the visit• Copy forward from the prior visit• Screening (e.g., g, “wants to check the health of my eyes”))•Naïve (e.g., “you sent me a postcard”)• Routine (e.g., “wants new eyeglasses”)• Default (e.g., “needs an eye exam”)Best PracticesChief Complaint• Separate chief complaint (CC) from history of presentillness (HPI)• Make two distinct fields• Anyone can make a notation in CCComplaintLocationQualitySeverityModifying FactorTimingContextDurationAssociated SignsBest PracticesChief ComplaintBest PracticesHistory of Present Illness• For the HPI, the physician must “perform” this part ofthe history, but the scribe can “document” it• Use an attestation if the scribe types the information inthe recordCCBest PracticesHistory of Present Illness___________________________________________HPIPerformed byscribed byCorcoran Consulting Group (800) 399-6565 www.corcoranccg.com

Best PracticesHistory of Present Illness• Get into the habit of using not less than 4 HPI elements• E/M coding relies on HPI as an essential element forthe level of serviceComplaintLocationQualitySeverityModifying FactorTimingContextDurationAssociated SignsBest PracticesHistory of Present IllnessRecheck AMD per Dr. SmithOUBlurry vision at nearA lotWhile readingDry AMD for 2+ yearsBest PracticesReview of Systems• Ask “Do you currently have problems in the followingareas?”• Don’t use a prior ROSReview of SystemsSystem Do you currently have any of these problems?EyesPoor vision, eye pain, tearing, redness…General Fever, weight loss, weight gain, unusually tired…ENTStuffy nose, ear ache, cough, dry mouth…CardiovascularHigh blood pressure, racing pulse…Respiratory Congestion, wheezing, shortness of breath…GIUpset stomach, diarrhea, constipation, hernia, ulcerGenital, Kidney Painful urination, frequent urination, impotence…Females only Are you pregnant? Nursing?Review of SystemsSystem Do you currently have any of these problems?Muscles, Bones Joint pain, stiffness, swelling, cramps…SkinPimples, warts, rash, growths…Neurological Numbness, headache, seizures, paralysis…PsychiatricAnxiety, depression, insomnia…Endocrine Diabetes, hypothyroidBlood, Lymph Bleeding, anemia, cholesterolemia…Immunologic Allergies, sneezing, swelling, redness, hives, lupusPotential ProblemsExamination• Use caution:• Defaults (WNL)• Copy forward (prior notation)•Symmetrical entries (same for both eyes)y ( y )• Universal completion (all elements always noted)Corcoran Consulting Group (800) 399-6565 www.corcoranccg.com

Best PracticesExamination• Make original entries• Use drop downs• Note each eye separately• Verify entries before closing the record• Preserve credibilityBest PracticesAssessment• Make primary diagnosis agree with the CC• Record relevant systemic illness (e.g., DM)• Don’t use diagnoses that no longer applyBest PracticesDiagnostic Tests• Record an order for the test• Chart an “interpretation and report”Chart DocumentationDiagnostic Tests• Physician’s order – Why is the test desired?• Date performed – When was it performed?• Technician’s initials – Who did it?• Reliability of the test – Was the test of any value?• Patient cooperation – Was the patient at fault?• Test findings – What are the results of the test?• Assessment, diagnosis – What do the results mean?• Impact on treatment, prognosis – What’s next?• Physician’s signature – Who is the physician?Potential ProblemsCoding• Use caution:• Your computer selects the CPT code for the office visit• You always select E/M codesBest PracticesCoding• Use both E/M and eye codesCorcoran Consulting Group (800) 399-6565 www.corcoranccg.com

Comprehensive Eye Exam92004, 92014• Evaluate complete visual system• Initiate or continue diagnostic and treatment program• Documentation• History• General medical observations• Gross visual fields• Basic sensorimotor exam• External adnexa• Ophthalmoscopy• Dilation not required (some carriers disagree)Intermediate Eye Exam92002, 92012• New condition(or)• Existing condition with new problem• Initiate or continue diagnostic procedures, as indicated,and treatment program• Documentation•History• General medical observations• External ocular adnexa• Other exam elements as neededSource: CPTNew Patient Office Visit3 of 3 Key ComponentsEstablished Patient Office Visits2 of 3 Key ComponentsHX PF EPF DETAIL COMP COMPEXAM PF EPF DETAIL COMP COMPHX NA PF EPF DETAIL COMPEXAM NA PF EPF DETAIL COMPDMSTRTFWDSTRTFWDLOW MOD HIGHDM NA STRTFWDLOW MOD HIGHCODE 99201 99202 99203 99204 99205CODE 99211 99212 99213 99214 99215Best PracticesPhysician Signature• Only the physician “signs” the chartSignature Guidelines“For medical review purposes, Medicare requires that servicesprovided/ordered be authenticated by the author. The method used shallbe a hand written or an electronic signature. Stamp signatures are notacceptable.” . . .“Providers using electronic systems need to recognize that there is apotential for misuse or abuse with alternate signature methods. Forexample, providers need a system and software products which areprotected against modification, etc., and should apply administrativeprocedures which are adequate and correspond to recognized standardsand laws. The individual whose name is on the alternate signaturemethod and the provider bears the responsibility for the authenticity ofthe information being attested to. Physicians are encouraged to checkwith their attorneys and malpractice insurers in regard to the use ofalternative signature methods.”Source: CMS Transmittal 327, March 16, 2010Corcoran Consulting Group (800) 399-6565 www.corcoranccg.com

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