In the world of compliance, you hear a lot of stories about the things providers do to make their lives just a bit easier. Copy and paste, templates or good old fashion cloning are all methodologies that are utilized by enterprising providers to try and make their lives a bit easier. The administrative burdens that are out there dictate that efficiencies need to be discovered and implemented. Unfortunately, many of the short cuts taken are not only non-compliant with internal policy; they may very well be non-compliant with regulatory standards. The advent of the electronic medical (health) records or EHR, has afforded providers the luxury of adding medical information with just a few clicks. This is, of course not without its own hiccups, but generally the frustration is more with the general cost of implementation of EHR rather than its utilization.
That brings me to the first and a fairly common way to cut corners I see among my clients, record cloning in EHR. Cloning involves copying and pasting previously recorded information from a prior note into a new note. Often times, this is done when a particular patient is seen with regularity and the status of their condition doesn't appear to change. On the surface this may seem entirely appropriate. However, if providers fail to review the previously entered information and update it with necessary changes, the medical documentation inconsistent, and the accuracy dwindles. The medical record must contain documentation showing the differences and the needs of the patient for each visit or encounter, and if a review isn't conducted, then that documentation may not be sufficient for the purpose of care OR billing. The cloning problem becomes especially compounded when the cloned records jump between patients — risking not only inaccurate information but a potential concern with securing confidential information. Working in compliance and reviewing records, you'd be surprised by how many pregnant men there are in any given system.
Upcoding, whether done with intent or not, can be a significant problem in EHR systems. CMS refers to this as "code creep" and cites EHR as a potential hazard. EHR systems allow providers to utilize auto-fill templates to input information. If not carefully monitored, the wrong codes may be included and result in a code that was not substantiated by the accompanying documentation. Plenty of provider groups and facilities have checked in place to ensure these codes aren't billed, but smaller and more economically challenged providers may struggle to quality check prior to seeking reimbursement. The transition from paper records to EHR has been a decade long process that many providers still struggle to implement. The important thing to remember that many errors and problems can be avoided with an engaging quality assurance program working in conjunction with the compliance component. Educate and train staff to watch out for these pitfalls and EHR can be a great addition rather than a frustrating obligation.
Joel is a Managing Associate at Source 1 Healthcare Solutions. He has experience investigating compliance and FWA within many facets of the healthcare industry.