It’s always interesting to hear a doctor’s perspective on compliance, but it’s even more interesting when that doctor happens to be the OIG’s Chief Medical Officer. I had the pleasure of hearing her, Julie Taitsman, MD, JD, speak at the HCCA’s Regional Compliance Conference this May in New York City. I listened intently as she addressed some common compliance issues. It was truly inspirational and interesting.
She talked about the never-ending discussion of physician documentation in regards to billing Evaluation and Management (E/M) and other codes. Some physicians are potentially documenting too extensive for the medical necessity of the actual encounter. They have either learned the documentation rules so well and/or they are utilizing electronic medical records (EMR) programmed in a way to make sure no E/M elements are left out that many notes are ‘over-documented’ so to speak. There is always a balancing act between too little and too much documentation but it was stressed that just because there is extensive documentation to support the highest level of E/M code (typically a ‘level 5’), that doesn’t mean all of that documentation was medically necessary. And if a level 5 was not medically necessary it shouldn’t automatically be billed just because the documentation guidelines for a level 5 are technically met.
Dr. Taitsman said the OIG is “technology agnostic,” and explained that regardless of whether the physician is documented in paper record or is using the most sophisticated electronic medical record, the documentation needs to be complete, accurate, and timely information. She elaborated by saying it was just as bad to not ‘unclick’ an autofill statement from an EMR as it is to write a false statement into a medical record as both result in the ‘official’ medical record not having truthful information. Whatever system or process utilized by a physician to document in the medical record, it should “promote integrity,” according to Dr. Taitsman.
On the topic of ‘copy and paste’ or “sloppy and paste” as it is referred to by some people, she made it clear that copy and paste could have some legitimate uses, but whatever information is copied and pasted needs to be truthful and accurate. She shared an example of one medical record the OIG reviewed where the EMR appeared to have auto-filled the statement “I counseled the patient on smoking cessation” but the patient was unconscious during the encounter. Something in that medical record was not accurate.
Dr. Taitsman also asked, Is there one legitimate reason out there for disabling the audit trail function of an EMR? “If so, I’d love to hear it.” She was referring to the behind the scenes feature of most, if not all, EMRs to track the user’s identity of every entry into the medical record.
A concluding remark came as a response to an attendee's question, how is a medical coder ever supposed to dispute a physician’s medical record documentation on the grounds of it being too extensive and not medically necessary if the coder isn’t as clinically trained as a physician? Dr. Taitsman suggested that a coder should not have to be in the position of questioning actual Medical Necessity. She commented that there really needs to be clear, top-down messaging from organizational leadership so physicians feel the responsibility for appropriately documenting medically necessary services, which is to say don’t document too little or too much, or at least, not to bill for that highest level E/M just because the documentation meets all the technical guidelines when the underlying service didn’t medically require all the documentation in the first place.
This is an area where compliance programs could potentially review the medical necessity of the services billed, not just the documentation. Occasionally, this may mean engaging an external compliance professional with medical training to be involved in the review.
CJ Wolf
Questions or Comments?