Health Information Management

News: CMS/ONC address EHR documentation concerns

CDI Strategies, August 1, 2013

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Documentation in the EHR can have a significant impact both from data reporting and reimbursement standpoints, said Sue Bowman, MJ, RHIA, CCS, FAHIMA, senior director of coding policy and compliance at AHIMA, during a listening session CMS and the Office of the National Coordinator for Health Information Technology (ONC).

One benefit of an EHR is that it can enable more complete documentation. This in turn enables more complete coding. More complete coding can lead to increased reimbursement. "So it's no surprise that these are all related," she said.

However, several features of the EHR can potentially enable fraudulent activities, Bowman said. These include cut-and-paste functionality, auto-­creation of documentation, single-click template notes, templates with limited options, E/M code optimization alerts, and "make me an author" functionality. "Make me an author" allows clinicians to assume authorship for a previous clinician's note without showing attribution

She identified the following goals to ensure compliance:
  • Develop organizational policies/procedures for proper use of EHR documentation
  • Provide comprehensive training/education to users on proper EHR use
  • Monitor use of EHR documentation features
  • Adopt a national set of coding guidelines for hospital reporting of ED and clinic visits

Upcoding is certainly a concern that requires further investigation, said Jonathan Blum, deputy administrator and director for the Center of Medicare at CMS. "We don't see evidence of [upcoding]. It's too early in our data, but we are mindful of the concern," he added.

Editor’s Note: This article originally appeared in Briefings on Coding Compliance Strategies.

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