AHRQ and HealthIT.Gov Post EMR Information

The Agency for Healthcare Research and Quality (AHRQ) has posted an Electronic Health Record (EHR)  primer for physicians and hospitals.  This primer provides guidance for providers in the use of EMRs.  The AHRQ’s mission:

The Agency for Healthcare Research and Quality's (AHRQ) mission is to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable, and to work within the U.S. Department of Health and Human Services and with other partners to make sure that the evidence is understood and used.

The AHRQ primer references the Safety Assurance Factors for EHR Resilience (SAFER) guides, developed by HealthIT.gov, the official site for Health IT Information.  Because certified EHRs are part of CMS’ quality programs in FFS Medicare, the guides were developed to aid providers in the implementation and use of them.   

The SAFER guides provide  an additional resource for providers seeking information on EHRs.  The following SAFER guides are available:

·         High Priority Practice

·         Contingency Planning

·         System Interfaces

·         Computerized Provider Order Entry with Decision Support

·         Clinician Communication

·         Organizational Responsibilities

·         System Configuration

·         Patient Identification

·         Test Results Reporting and Follow Up

Finally, AHRQ has developed free CME (1 CME unit for American Board of Internal Medicine) and Medical Knowledge/Patient Safety credit (up to 45 MOC points).   There is a related CME program, The Hazards of Distraction: Ticking All the EHR Boxes available on the AHRQ site (registration required).

We hope this information is helpful.

CMS Offers New ICD-10 Content

As part of their ongoing "Road to 10" series, CMS has posted a newly released webcast on ICD-10 documentation and coding concepts for cardiology.  You can access this webcast here, on the webcasts page of The Road to 10: The Small Physician Practice's Guide to ICD-10 website.


An AHIMA-certified coder presents on the webcast, which focuses on unique ICD-10 clinical documentation needs and hot topics for cardiology:

• • Physician perspective/clinical impact of ICD-10
• • Documentation requirements for certain conditions
• • Documentation changes and new concepts
• • Use of "unspecified" codes in ICD-10

In addition to the newly posted Cardiology webcast, you can find webcasts geared toward Orthopedic Surgery, OB/GYN and Pediatrics.   There will soon be a Family Practice/Internal Medicine webcast as well.  

In addition to these specialty geared webcasts, the website contains a wealth of ICD-10 related information, including a guide to building an action plan, and templates that you can use with that action plan.

We encourage you to visit the website for authoritative information on ICD-10-CM.

ICD-10 Rural or Urban; It Impacts All Providers (+playlist)

This CMS video discusses the impact of ICD-10 Implementation on all providers.

For physcians and other treating clinicians, one of the most important considerations is documentation.  If you accurately and concisely document a disease, then you have the best chance of you or your coder finding an appropriate ICD-10 (or ICD-9) code.

I hope this video is helpful.

What's New on HCC University?

We've continued to add a number of documents to HCC University to make your documentation and coding go more smoothly!

We've updated our Annual Wellness Visit (AWV) with Health Risk Assessment (HRA) package to incorporate information on 5Star coding.  Since physicians are already capturing the data, we want to help make it easy to remember to submit it on the Superbill.  You can also review a presentation on completing the AWV with HRA.

We'll be posting more documents on HCC University in the near future. 

HHS and DOJ Issue Joint Letter on Cloning of Medical Records

On September 24, 2012, Secretary Katherine Sebelius of the Dept. of Health and Human Services, and Eric Holder, Attorney General, of the Department of Justice, issued a joint letter to several health care associations, including the American Hospital Association and Federation of American Hospitals. You can view a copy of the letter on HCC University, on our Tools page.

Although the letter applauds the widespread adoption of EHRs, it notes that there are indications that some providers are using them to clone records and to game the system.  The letter points out that this type of false is not only dangerous to the patient, but also illegal. 

The letter notes that CMS is stepping up its medical record review activities to identify these issues, and that the DOJ, FBI and other law enforcement are monitoring these issues and will take action when warranted.

So--how do CMS, the DOJ and others identify cloned medical records?   Cloned records are often very obvious.  Although they may occur in handwritten records, it is most often found in EMRs with cut and paste and template functionality. 

Although templates are not inherently bad, auto-populating them indiscriminately with information can lead to obviously cloned records. While some things may not change significantly from visit to visit (for example, the bulk of the patient's history may remain the same), a patient's condition is rarely, if ever, static.  A patient's interim history, vital signs, symptoms and treatment are almost never exactly the same. Copying and pasting these components leads to inaccurate medical records.

Another area where cloning becomes obvious is in the assessment.  Often, previously treated or self-limiting diseases remain in the assessment for months or even years.  We've seen charts where a diagnosis of "acute sinusitis" continued on for over a year, with no treatment after the initial date of service where it appeared.

It's important to remember that once one part of the medical record is obviously wrong, and auditor is likely to discount the record in its entirety, since it's impossible to tell what is and isn't accurate.

Clinicians using EMR should use templates wisely, and cut and paste functionality very sparingly.  All information in the chart should accurately reflect the patient's complaints, conditions, and treatments on the current date of service.

OIG Posts Podcast on the Importance of Documentation

The OIG has posted a podcast on the importance of medical record documentation.  You can listen to the podcast or view the video by going to the podcast page.

If you can't listen to the podcast, you can review the transcript, here.

New Presentation on HCC University

There's a new presentation and quiz on HCCUniversity.com!  Check out Documentation for Ophthalmology coding.  This presentation should help Ophthalmologists and Optometrists understand ICD-9 coding requirements.  Go Here and scroll down to the first downloadable presentation!

Documentation--Why Bother?

Today, we have a guest posting from Debra Braden, CPC, CUC, HCC Coding Project Specialist in our Risk Adjustment Data Validation (RADV) department.

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Since the advent of the HCC model, documentation has become more important than ever.  Because CMS reimburses for HCC’s they will also conduct audits to make sure the payments were justified.

There are other reasons that documentation is important.  Good documentation can help protect both the patient and the physician.  It is good patient care to clearly document why the patient is having the visit, the conditions they have and what the plan of treatment is.  This aids the current and any subsequent healthcare providers in knowing exactly what is going on with the patient and enables them to monitor and/or treat conditions.  Another important reason is in the case of a malpractice issue.  The court would be able to clearly see what is wrong with the patient and what the physician has done to care for the patient.

In order to pass CMS or Plan audits there is information that should be included in the medical record.  The patient’s name and one other identifier (date of birth, medical record or chart number) should be on every page.  The date of service, legible signature and credentials must be documented.  For a new condition the documentation should include the diagnosis, rationale, any related labs used for assigning the diagnosis and the plan of treatment.  For an established condition the documentation should include the diagnosis, status of the condition and the plan of treatment.

Based on findings from the Medicare Advantage Risk Adjustment Data Validation CMS-HCC Pilot Study several errors were found to be common.

·        Documentation to substantiate the diagnosis code was not in the medical record.

·        Chronic conditions coded but not documented in the report at the time of the visit.

·        Documentation was not in the medical record to support the specificity of conditions.

·        Truncated codes - Not using required 4^th or 5^th digits.

·        Physician unable to locate the medical record.

·        Coding for rule out, questionable or suspected conditions in the office.

·        Coding for acute conditions when the patient was status post or had a history of the condition.

·        Selecting codes incorrectly from superbills.

·        Not coding for documented conditions.

Keep in mind that just because an Electronic Medical Record is used doesn’t mean that it will automatically pass an audit.  Cloning notes from prior visits that a member had with a physician can cause inconsistencies within a note that would make it difficult for a certified medical coder to abstract a particular diagnosis even if it meets the criteria:  a) state the diagnosis, b) show logic or assessment and c) state plan.  Other problems can arise from use of an EMR including the use of an incorrect diagnosis selection lists.  The one thing that EMRs will solve is legibility, but unless intelligent notes are implemented, don’t expect an EMR to help you attain appropriate documentation.

Also keep in mind that good documentation doesn’t mean that the medical record has to be lengthy.  Good documentation simply means that specific information should be in the documentation that shows that a condition was evaluated and/or treated on the date of service.