Documentation traps in the world of EMRs
[This quarterly column is written by Caral Edelberg, CPC, CPMA, CAC, CCS-P, CHC, President of Edelberg Compliance Associates, Baton Rouge, LA.]
So you implemented an EMR product that's supposed to give you everything you need to document your services to Medicare standards. Or, the vendor assures you that their product will support your services in an audit if you follow the prompts. Unfortunately, your compliance department still dings you when they audit your ED charts. So, what gives?
The fact is that no documentation system can automatically provide the prompts necessary to fill in all the blanks necessary due, in part, to:
- Rapidly changing regulations;
- Subjectivity of ED coding rules;
- Focus of payer audits;
- Lack of physician familiarity with coding/compliance rules;
- Relationship between presenting problem, interventions, and final diagnosis and disposition.
Take, for example, the variability in documenting medical necessity. In the ED we work primarily from the presenting problem, risk factors, differential diagnoses, and the limited information available from prior visit records — all components of physician medical decision making. Interventions, which come later in the patient course, are based on these crucial factors — even when standing orders are utilized. The visit, documentation, interventions, and decision making start there and are developed through the ED course. Let's start with some of the more common deficiencies that require thoughtful consideration when documenting a chart, whether prompted or not.
Importance of the Presenting Problem
The presenting problem is significant for medical decision making only with regard to what is done about it. This would include the development of additional history to identify risk factors and co-morbidities related to the problem, the extent of the physical examination related to the problem and the identified risk factors from the exam, and, most important, the decisions made for ordering diagnostic studies and interventions based on this information that paint a picture of the "whys" of treatment. Thus, ordering a ton of diagnostic tests and interventions without stated rationale may be extremely misleading to an auditor.
Why "NAD" on a sick patient?
"Patient in no acute distress, resting comfortably, improving" paints a totally different picture than "although patient seems to be feeling better after treatments, I am still concerned for the underlying cause of this shortness of breath," etc. If, from a clinical perspective, a provider feels the need to establish that the patient is no longer in distress, it should be followed with the reasons why. If it is ED interventions that improved this patient, it needs to be said.
Differential diagnoses
Recording of differential diagnoses got a bad rap somewhere in the past, and ED physicians stopped documenting them for a time. Of course, a "medical student" listing of everything that might possibly be wrong with this patient may not be relevant. However, referencing the possibilities/probabilities to support interventions and patient disposition are invaluable when relevant to the chief complaint and risk factors.
"Patient refused" and its place in medical decision making
We have seen an increasing number of patients either refusing IV medications/narcotic drugs, high-priced diagnostic studies (CT, MRI, Doppler), and/or admission to inpatient status. Perhaps patients are becoming more and more cost conscious as lack of insurance can result in numbing medical bills. However, the medical decision-making might actually support a higher level of complexity in order to find an acceptable alternative to assure a positive outcome for the patient's problem. These decisions made by the patient rather than the provider may actually increase the risk for the ED patient. It's important to address this in your documentation to support the additional medical management necessary to protect the patient during the interval period between the ED visit and the "next step" which, of course, should be detailed in the medical record.
Critical care and why it is still the $64,000 question
Why is critical care such a difficult concept to grasp? Is there an objective means of determining whether or not a patient qualifies as critical? The descriptors for critical care remain somewhat subjective without information in the record that addresses the following:
- Identification of the organ system at risk;
- Steps taken to stabilize the patient or prevent additional decrease in system function;
- Comorbidities/risk factors that contribute to management of the patient;
- Steps taken by the EDMD to stabilize, reverse, improve, address potentially life- or limb-threatening outcome;
- Key concepts include thorough assessment of problem and risk factors; steps taken through manipulation and study to stabilize and/or prevent further failure; methods of support to stabilize and reverse system failure.
- Time spent managing the patient that clearly indicates (a) patient is critical; (b) addresses whether or not condition is stabilized; recommends disposition and life-/limb-saving orders.
The physician, and only the physician, should determine whether or not the patient is considered critical. When reviewed by auditors, the critical nature of the problem and treatment should be clear and never only implied. However, because there are no objective scoring systems available to assist with this determination, it's up to the coding, compliance, and clinical staff to collaborate on how critical care is determined, coded, and supported on audit. For example, certain drugs and interventions provide a clear picture of a patient in critical condition. However, without supporting documentation of time and management throughout the patient's ED stay, it may be virtually impossible to assure the visit is coded appropriately or, on audit, assure documentation clearly supports the work performed.
Sick people going home
Defending higher levels of service when the patient is discharged will be increasingly difficult on RAC/MAC/MIC audits. So, when the patient's condition requires a high level of intervention, don't expect the orders alone to defend your medical decision making. The concept of "ED Course" is alien to many auditors accustomed to reviewing office and clinic notes where much of the workup and stabilization is referred out.
All things being equal during the ED course, disposition alone should not determine whether or not a 99284, 99285, or 99291 critical care can be billed. However, some pretty reliable former Medicare staffers indicate that Medicare is looking closely at percentage of admitted patients to be in the ballpark of the 99284, 99285 and critical care billed percentages. So, when patients who receive extremely comprehensive workups are discharged, additional documentation should provide support for the need for workup, the risk to the patient from the condition necessitating the workup and interventions, treatment provided, and the reason why admission to the hospital did not occur.
Nursing notes
Nursing notes in an EMR can be difficult for nurses and reviewers. Nurses correcting entries time and time again (Yes, it happens!) provide a confusing picture of patient care and can result in significant coding errors. Absence of times for timed procedures prevents coding of services that contribute to the financial bottom line in emergency departments. Some tips that may help clarify what is needed include:
• Timed Entries
Don't rely on the time a note is entered to validate the time a procedure is started and stopped. Many entries happen well after the procedure. Nurses need to accurately document start and stop times for infusions and injections, bedside start and stop times for critical care, start and stop times for observation, and timed entries for all interventions.
• Progress Notes
As with physician entries, the condition of the patient throughout the ED course supports needed interventions. If a sick patient is resting comfortably, visiting with family, watching TV, reading a book. and/or eating a sandwich, he or she may not appear sick. However, nursing notes that support the impact of negative test results, additional interventions (breathing treatments, IV medications, and the rationale for additional or alternative medications, risk from narcotics, etc.) go a long way to paint a true picture of the patient's clinical status in the ED.
• Patient Assessments
Does a peek in the door to observe a resting patient count as an assessment? Does taking vitals, speaking with family members to discuss care, quantifying pain levels and administering medication, and providing comfort to a patient say more about patient status? If there is a difference in these two types of interventions (and I believe there is!) then how do these translate to your assessment criteria for use in determining an accurate level of service?
If your E/M level is determined in part by the number and/or type of assessments and they aren't clearly defined, you may be over-coding or, in some cases, under-coding your services. Take a look at your nursing assessment criteria and consider a tweak to better define nursing interventions/assessments. Timed assessments on the EMR may not be an indicator of the actual times and extent of the assessment. Consider expanding the information provided to accurately capture your resources.
In summary, EMRs will, eventually, prove to be an invaluable tool for emergency medicine. However, most are in their infancy and will require provider and compliance input to improve their usefulness to the level we will require to meet the challenges ahead. Work with a team consisting of providers, compliance, vendor representatives, and business office staff to develop documentation policies and tools that paint an accurate picture of services, times, and medical necessity that strongly support services and minimize denials.
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