Recent changes to the Health Information Portability and Accountability Act (HIPAA) have brought stiffer penalties for fraud prevention, with new levels of enforcement among smaller and independent medical practices. Electronic medical record users should be aware of issues that pertain to electronic documentation compliance, including patient identification and demographic accuracy; and documentation, auditing and authorship integrity. This webinar reviews these and other concepts, including: Are you “gaming” the EMR? Locking the record before billing Cut and paste rules Macro/template rules Using a scribe Choosing the E/M Code Closing the order to bill Rules for split/shared visits Rules for documentation by medical students and residents Providing a well visit and a sick visit at the same time

1. Sponsored by:
Adding to Your
Compliance
Toolbelt: Fraud
Prevention in Your
EHR/Clinical
Documentation
April 23, 2013
Mary Pat Whaley, FACMPE, CPC
Manage My Practice, LLC

2. About Hello Health
Based in New York City
80 employees
27 states
Cloud-based technology coupled
with a unique business model (no
cost revenue-generating EHR and
patient portal)

3. Today’s Speaker
3
Mary Pat Whaley, FACMPE, CPC
• 25+ years in physician practice
management
• Founder of Manage My Practice,
destination website for physician
practice management information
and resources
• Expert in Revenue Cycle
Management, Practice Management
and Electronic Medical Record
Management

4. Overview
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PROMISES PROBLEMS
• Structured Data • Structured Data
• Accessibility • Accessibility
• Meaningful Use • Meaningful Use
• Efficiency • Efficiency
• Space Saving • Space Saving
• Transcription
Savings
• Lack of
Transcription
• Improved Charge
Capture
• Improved Charge
Capture
• Alerts • Alert Fatigue

5. Are You Gaming the EMR?
Uproar in September 2012
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• The Center for Public Integrity publishes “Cracking the Codes”
http://bit.ly/upcoding suggesting that costs from upcoding and other abuses
likely top $11 billion between 2001 and 2010.
• Attorney general Eric H. Holder Jr., and secretary of health and human
services, Kathleen Sebelius sent a letter to five hospital trade associations
stating, “There are troubling indications that some providers are using this
technology to game the system, possibly to obtain payments to which they
are not entitled. False documentation of care is not just bad patient care; it’s
illegal.”
• AHA President and CEO Rich Umbdenstock responded “more accurate
documentation--a presumed result of EHR use—is not the same thing as
fraud. “The AHA is still waiting on the Centers for Medicare & Medicaid
Services to adopt national evaluation and management guidelines to help
clarify increasingly complex payment rules.”

6. Are You Gaming the EMR?
Uproar in September 2012
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What do you think?
Is it false documentation of care or are you
simply documenting care for which you failed to
collect with a paper system?

7. How is EMR documentation achieved?
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• Check Boxes
• Check Phrases
• Free Text
• Dictation/Transcription
• Scribes
• Virtual Scribes
• Voice Recognition
• Handwritten

8. Rule #1: The medical chart is a legal record
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• Name, Patient DOB and DOS (on every page if paper)
• Chief Complaint
• Documentation of visit: Must demonstrate medical necessity or
evidence of a face-to-face encounter with the patient
• Legible signature and date
The medical record is a legal document – would you
put your name to a document that you had not
reviewed?

9. Rule #2: If you didn’t document it, you didn’t do it.
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• Documentation isn’t done after every patient.
• EMR allows billing of charges without completion of
record.
• Patient never returned so no one noticed the
documentation wasn’t complete.
• Charging is not done through the EMR so charges got
entered before the documentation was done - no
reconciliation of charges to documentation.
• Physicians leave the practice without completing the
record.

10. Rule #3: Every note stands on its own.
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With very few exceptions, each note must be intact and
include all information contributing to the level of
service.
The exceptions are:
• Resident Notes
• Mid-level provider (MLP) notes for split/shared
visits
• Addendums to the original note
EMRs handle resident and MLP notes differently – some
allow notes by different providers to be part of the same
note, and some do not.

11. Rule #3: Every note stands on its own. (Copy and
Paste, Cloning, Copying or Carrying Forward)
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Definition: Copying previous documentation (same or
different provider) to a note on another day, another part
of the record, or even another patient’s chart.
Dangers:
 Copying non-relevant data (e.g. entire problem list or
even another patient’s PHI.)
 Copying inaccurate or outdated information.
 Contradictory information.

12. Rule #3: Every note stands on its own…and is
expected to be unique. (Templates, Macros and
Cloning)
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Templates guide providers through the documentation process
and prompt them to cover all standard areas of the patient visit.
Macros are blocks of text that can be “exploded” to describe
standard text that applies to a service or a portion of the visit.
Some macros are a standard line that is required such as “I have
examined the patient and have reviewed the evaluation
documented by Dan Jones, NP, and agree with his assessment
and plan.”Some macros are entire paragraphs of text that allow for
customization of detail.
NOTE: If an EMR converts a checklist into sentences, so that the
medical records of two different patients seen for the flu are
indentical, you may raise a red flag! http://bit.ly/12DgTlQ

13. Rule #4: Thou Shalt Not Use Exception
Documentation
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Exception documentation means “all systems normal with
the exception of…”
Exception documentation concerns auditors because it
indicates that system are being called “normal” without
actually reviewing each system.
One acceptable way to document is to click on all the
individual systems examined, and to free text detail on any
systems with abnormalities.

14. Using Scribes
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The Joint Commission defines a medical scribe as an
unlicensed individual hired to enter information into the
electronic health record (EHR) or chart at the direction of a
physician or licensed independent practitioner. Scribes are
not permitted to make independent decisions or
translations while capturing or entering information into
the health record or EHR beyond what is directed by the
provider.
• Scribes must login under their name/password.
• Scribes may not enter orders.
• Scribes may not complete/lock charts.

15. Calculating the E/M Code
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Some EMRs include an E/M calculator, or have you identify
the levels of HPI, Exam and MDM, then suggest the level
of service that corresponds.

16. Split/Shared Visits
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A split/shared E/M visit is an inpatient encounter where the physician
and a qualified Non-Physician Provider (NPP) each personally perform
a substantive portion of an E/M visit face-to-face with the same
patient on the same date of service. A substantive portion of an E/M
visit involves all or some portion of the history, exam or medical
decision making key components of an E/M service.
Both the physician and the NPP must document the part(s) that he or
she personally performed – the NPP cannot document for the
physician.
There should be “bridge statement” that connects the two notes
(whether on the same physical record or not), stating that the
physician reviewed the documentation of the NPP (by name) and
agrees with the plan and assessment, with or without changes.
Typically, the physician performs the examination, even if the NPP
examined the patient as well.

17. Medical Students
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1. Medical students services are not billable on their own.
2. A medical student’s documentation for Review of Systems
(ROS) and Past, Family and Social History (PFSH) may be
used to support clinical documentation and billing.
2. Attending physicians may NOT refer to a medical student’s
documentation of history of present illness, physical exam
findings or medical decision making to support billing
documentation.
3. The attending physician should review the information
with the patient, reference the student’s note and
document any additions/changes.

18. Residents
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1. Resident services are not billable on their own without
any attending attestation.
2. A resident may perform the entire visit, however the
attending must review his documentation.
3. The attending physician may examine the patient OR
evaluate the patient, reference the resident’s note and
document any additions/changes. Most healthcare
organizations expect the attending physician to “lay eyes”
on the patient, even if they do not examine the patient.
4. The resident’s and attending’s documentations are
expected to be done on the same calendar day.

19. Well and Sick Visit Same Day: One Record or Two?
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CPT® says: “If an abnormality/ies is encountered or a
preexisting problem is addressed in the process of
performing this preventive medicine evaluation and
management service and if the problem/abnormality is
significant enough to require additional work to perform
the key components of a problem-oriented E/M service,
then the appropriate Office/Outpatient code 99201-99215
should be reported. Modifier 25 should be added to the
Office/Outpatient code to indicate that a significant,
separately identifiable E/M service was provided by the
same physician on the same day as the preventive
medicine service. The appropriate preventive medicine
service is additionally reported.”

20. Your EMR Compliance Toolbelt: #1 Create a Billing
Compliance Policy or Update Your Current Policy
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1. What is the responsibility of each person in the
practice who documents in the EMR? (scribe, MA,
technician, provider)
2. If the medical record and the charges are not
interdependent, what is the rule for completing
documentation before the charges are entered or
the claim is dropped?
3. Is there a turnaround time for all provider
documentation to be complete?
4. Is there a reconciliation process for making sure all
documentation is complete (“locked”) and all
charges are entered?

21. Your EMR Compliance Toolbelt: #1 Create a Billing
Compliance Policy or Update Your Current Policy
21
5. Are there rules for cut & paste and other methods
of copying documentation from one visit to
another?
6. What are guidelines for medical record
addendums?
7. What is the rule about providers emptying their
Inboxes before leaving for the day? How are test
results handled during a provider’s absence (day
off?)
8. Check with your malpractice carrier on EMR to see
if using an electronic record increases or decreases
risk and why.

22. Your EMR Compliance Toolbelt: #2 Understand Your
Electronic Medical Record
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1. Is the person who set-up the EMR still employed
with the practice? If not, does someone else
understand the set-up?
2. Do you send someone to a user’s group meeting, or
have them on a listserv, or in touch with other
users?
3. Do you print out the medical record on a regular
basis and see what it looks like to others – for
instance, a payer or an expert witness in a trial? Can
a non-physician look at the record and understand
what happened at the visit?
4. Are you using the EMR’s full power?

23. Your EMR Compliance Toolbelt: #2 Understand Your
Electronic Medical Record
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5. Do you know more now than you knew when you
started with the EMR, and can you use that
information to make changes? Are there tweaks
you can make that would improve the medical
record?
6. When was the last time someone watched the
providers documenting to see what steps they take
and if they are using the system as efficiently (and
correctly) as possible.
7. Providers! You are legally responsible for the
medical record, not the EMR vendor.

24. Your EMR Compliance Toolbelt: #3 Managing
Downtime
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If you continue to see patients during EMR downtime
(and most practices do), make sure you have a written
Downtime Protocol that covers:
• Documenting a visit
• Ordering tests & procedures
• Making referrals
• Writing prescriptions
• Charging for the visit
• Patient recall

25. Thank you &
discussion

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Mary Pat Whaley, FACMPE, CPC
•www.ManageMyPractice.com
•marypat@managemypractice.com
•(919) 370-0504