Adjusting to a Paradigm Shift in Documentation

The exam room is about to get a bit more crowded. Now, in addition to you and your medical assistant, your patient's insurer will be looking over your shoulder to make sure that what you do and what you have documented is “medically necessary.”

While “medical necessity” has long been the standard for reimbursement for things like a coronary artery bypass and hemodialysis, payors are now about to get a lot pickier in the out-patient setting. According to the CMS Medicare Claims Processing Manual's last revision in August of 2011, “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed.”¹

Documentation Isn't Enough Anymore

For decades, physicians would simply submit a bill and be paid in full by the payor. The medical notes merely consisted of a few short sentences through which the physician could recall what had been done or to communicate with another physician. But the world of the brief paper chart was rocked when CMS released the “1997 Documentation Guidelines for Evaluation and Management Services” which consisted of history, exam, and medical decision making bullets that had to be recorded in order to be properly reimbursed.² EMR companies responded by creating macros and templates that used the same phrases over and over again to meet billing targets. And it worked. Savvy physicians were able to bill at high levels through their documentation. But, today, as more physicians utilize EMRs, the improved documentation is proving to be an area of significant expenditure for Medicare as well as for private payors. Since it is now much easier for physicians to simply “cut and paste” entire sections of a patient's prior note and quickly turn the documentation for a 99213 visit into a 99214 visit, CMS has declared that it will not pay for this seemingly unjustified “upcoding.” Basically, the old adage, “if it wasn't documented, it wasn't done” is about to be replaced by, “if it was documented, it possibly shouldn't have been done and you're not getting paid for it.”

Dermatology billing specialist Inga Ellzey recently illustrated the problem quite well when she argued that a 99214 code, while justified by the physician's documentation, may not be justified by the patient's actual condition. Take, for instance, the example of a patient coming in for a follow up, problemfocused visit. Ellzey asks, “Why does the patient need another full-body examination three weeks (after the last one)? Even a waist-up exam would be questionable.”³

Under the new guidelines, templating notes, which once solved physicians' documentation problems, have created an entirely new documentation problem that Ellzey and others refer to as “cloning.” So, if Mr. M's note for acne looks exactly like Mrs. C's note for acne, which looks just like Mr. W's, you could be accused of “cloning” your notes.

Ms. Ellzey provides the example of a review of systems that included the lack of a pacemaker on someone quite unlikely to have one. Charts had duplicate entires, including the pacemaker note for a three-year-old patient! “This type of cloning makes all the other chart notes questionable for fraud,” she said.³

Therefore, when documenting a patient encounter, it is important to be mindful to only make note of those things that are truly useful for the care of the patient—in other words, what is “medically necessary.” Probably only a very small percentage of physicians willfully document incorrectly to increase billing. The vast majority are likely just busy; whatever gets one through notes more quickly and on to actually caring for patients, is the most likely course of action. Thus, we may be more inclined to “cut and paste” or to use premade templates to get the odious task of note-writing done quickly.

In 2003, one of the first adopters of EMR, the Veterans Administration, took notice of the broad incidence of note copying and cloning and made the following recommendations for EMR development:

1. Re-engineer templates to avoid unnecessary duplication artifact.
2. Minimize inserting patient data available elsewhere into the narrative record.
3. Develop medical history and examination data objects that can be reviewed, amended and re-used.⁴

Unfortunately, many older EMR systems have not incorporated the changes necessary to avoid potential documentation cloning. A so-called certified product may not protect you from making these documentation errors, yet avoidance of these errors may become more important to your bottom line than any proposed government reimbursement. As Ellzey notes, “Medical necessity will be the catchphrase that will either make or break your practice's ability to support its services when audited moving forward.”³

How to protect yourself

As in 1997, medical documentation is about to undergo a paradigm shift. Macros and templates are out. Dynamic history, exam, and diagnosis objects are in. Copying and pasting are out. Automation of unique notes is in.

Some EHRs are taking note. Modernizing Medicine's EMA Dermatology product has made these concerns central to its design in an effort to help physicians document as quickly and as accurately as possible and provides a useful way to think about how to navigate the emerging “medical necessity” issues.

Addressing Kenric, et al.'s first point, EMA does not use templates to generate follow up notes, instead implementing a proprietary algorithm that for each disease stores the unique plans (treatment, surgery, biopsies) for unique dates (the visit dates) on unique body locations (1,300+ possible locations). This makes it possible for patients following up on similar conditions to have unique notes without sacrificing any of the physician's time.

The second point of the VA recommendations applies to many items in the medical record including past medical history and demographic information but seems to come up most critically in a physician's review of systems. As Ellzey points out, one usually need not ask a three year-old if they have a pacemaker or, for that matter, a follow up dermatology patient about heart palpitations. CMS has made clear that a follow up review of systems needs to be related to the chief complaint—why the patient is presenting. While many EMRs have a convenient “mark all” review of systems box, EMA helpfully warns doctors not to use this box for follow up visits and does not automatically carry a full ROS through visit to visit. Additionally, EMA reminds the user when the patient's last full skin check was, helping to avoid improperly performing one for an isolated lesion when the last skin check may have been only weeks before. This is also of great utility if the physician is able to quickly ascertain that it has been over a year for a patient who may be in need of an annual skin check.

The third, and potentially most dangerous point that the authors of the VA article highlight, is one that we have all likely seen. It is the problem of carrying a history or exam finding from note to note when that problem has since resolved. Worse, perhaps the pre-written template records a normal skin exam for a patient on whom a significant finding was dealt with in the note's impression and plan. Thus, the authors of the VA article correctly place the burden on the user's EMR to have “data objects” that should change from visit to visit. For example, EMA has a problem list “object” and medication list “object” that update automatically based on data input at the last visit, without adding extra steps. Because exam “data objects” are also linked to the diagnosis chosen by the user, it is not possible to have a normal exam for an abnormal diagnosis. Thus, the number of findings will always match the number of diagnoses in an EMA-generated note.

Outside of the VA recommendations, “medical necessity” also requires specific justifications documented for the given procedure performed in the dermatology office. For example, if one is documenting a surgical closure or destruction of a benign lesion, there needs to be justification for the procedure that is done. The associated phrases needed for surgical or procedural justification are offered to users of EMA as a tab from which one of up to a dozen procedurespecific phrases can be selected. This obviously also helps to create unique notes for different patients.

As recent years have shown, documentation, billing, and coding now and for the foreseeable future will be moving targets. As physicians trying to keep up with rapidly changing medical knowledge, also keeping up with the ever-changing rules for documentation can begin to feel onerous. One way to help relieve the burden is to make sure that the technology we use for documentation has the ability to change as fast as the rules do.

Michael Sherling, MD, MBA is Chief Medical Officer and Co-founder of Modernizing Medicine. He is in private practice in Lake Worth, FL.

1. CMS-Medicare Claims Processing Manual. Ch. 12, Section 30.6.1, Rev.2282.
2. https://www.cms.gov/MLNProducts/Downloads/MASTER1.pdf
3. Concept of medical necessity can support services when being audited. Ellzey, I. Dermatology Times. Sept. 1, 2011.
4. Are Electronic Medical Records Trustworthy? Observations on Copying, Pasting and Duplication. Kenric W. et al. AMIA Annu Symp Proc. 2003; 2003: 269–273.