We call it the good, the bad, the ugly. Most of electronic records are good. And the ability to get that information in the medical record, transmit it, send it to another physician for review or provider to review, print it off for your patients, all of that is great. But we've got a few little kinks in the electronic medical world. Kathy and I often get asked the question, which medical record system do you recommend? And our answer is pretty well, none, none of them. Not that they're horrible, it's just there's always, we always find things wrong with them. They're not gonna be perfect unless maybe artificial intelligence comes in and makes them perfect. But, so we're kind of stuck with some of the, you know, discrepancies in our notes, giving us the ability to clone, copy paste, those sorts of things, kind of get us into, again, someone looking at our records, scrutinizing them. So we're gonna talk a little bit about those issues. We're gonna talk a little bit about dictation and voice recognition software. And then I'm gonna end this with the CMS electronic record fact sheet. I was answering one of our support questions about a month or so ago, and it prompted me, it led me, my research led me to the CMS electronic record fact sheet. And I thought, well, I'll be darned, that's pretty good. That's a pretty good reference. And so I thought it'd be, you know, pertinent to put into this session regarding EMRs. So question before we begin, whose responsibility is it to ensure the documentation for a visit is accurate without any contradictions or misspellings? The billing provider, the medical assistant who enters part of the history, the patient, or Medicare? Good job. Yes, the billing provider, right? So ultimately, no matter if there are typos, if there are contradictions, if there's missing information, there's, you know, you did voice recognition system and a big old, huge entire conversation is put into your note that has nothing to do with the patient. I've seen all of it. Ultimately, the billing provider, the one that's on, the name is on the claim, is responsible for making sure that documentation is correct, no misspellings, no blanks, no contradictions before they sign that note. Remember, it's medical legal. All right, so safe use of templates. We're gonna talk a little bit about templates. And I know there's lots of templates out there. Templates are actually excellent if we use them appropriately and if we set them up appropriately. So, you know, most of the EMRs have the ability to do a, you know, template for a new patient, template for consult, template for a follow-up patient, template for a hemorrhoid banding. Whatever you're doing, there's a template I bet you can make for it. But we have to make sure that we utilize them. They're for prompts. That's what a template is for. It's a guide to make sure that we get the information in there that is necessary for patient care and for documentation purposes. So that's why it's so important when you're setting up templates. Medical necessity should be the driving factor for your templates. Every note should not look identical and must be specific to the patient's chief complaint. All right, so I have seen this where I can do an audit on office visits and they use the same EMR, the same template for every patient. And I can take five different patients with the different conditions and audit them. Every single one of them have the exact same review of systems and physical exam elements. And that should not be the case. Number one, we don't need it anymore. We've learned that today. And number two, it's gotta be pertinent to the patient and that encounter for that day, all right? Now, if I was reviewing this information with you and I sit down and going over these patients with you and you look up at me and you say, Kristen, I ask these questions every single time and I do these exam elements every single time, then that's good, okay? But if you don't, it doesn't need to be part of the record. So when you're talking about visits, okay? The chief complaint, we talked about the chief complaint. Number one, it's required. Number two, it needs to be specific. But the chief complaint should flow into your history of present illness and the problems addressed in the HPI should flow into the assessment and plan of care. And I've kind of been talking about that off and on today is our notes should flow. And a lot of times with templates, with electronic records, with someone else entering information into our records, I see a lot of disconnect in the flow of the note, okay? So I go from, wait, what was I just reading? Did that just happen? To, wait a minute, something, they did say all that, but now there's nothing in the assessment. So there should be a flow to the note. Telehealth, all right? So I know right now we're not doing a ton of telehealth, okay, the pandemic ended, payers are not so relaxed on telehealth documentation, but now that the public health emergency has ended, Medicare is reviewing telehealth documentation. So all those encounters they paid you for during the pandemic, they're pulling those records and making sure you document it appropriately. And I can tell you these telehealth visits, a lot of them out there are not documented appropriately, okay? So if you are still seeing telehealth patients, double check your template, okay? Definitely your physical exam on a telehealth. So an audio video exam, so you see the patient, you hear the patient, should only include general statements that can be commented on just by seeing the patient and not touching the patient, okay? We should not see bowel sounds present in all four quadrants and cranial nerve evaluations and things like that that are not possible unless the patient's right in front of you. Audio only encounters should never include a physical exam and we see that. So we either use the wrong template or we didn't update a template specific to audio only encounters, okay? So what happens? I pull up the template, I put in my information, I sign my note, I go to audit it and I'm like, wait a minute, you were on the phone with this patient, how do you have a physical exam? Okay, so again, the information's not pertinent, you leave it off the medical record. Address cloned documentation with your providers, use the basic SOAP note format for follow-up notes in both the office and hospital and keep it pertinent to the current encounter for follow-up care. I would much rather, and I say this all the time, I would much rather audit a one to two page SOAP note, like back in the old days when I first started coding, then an eight page copied note and 80% of it has nothing to do with what you're doing with patient. You know, five of the pages are labs the patient's had for the last two weeks while they're in the hospital and an X-ray of the ankle and an MRI of the brain and we're seeing the patient for GI bleed, okay? So keep it pertinent. If it automatically filters into your documentation, delete it if it has nothing to do with the care you're providing that patient. That just gives, it just gives someone the chance to, you know, ding you on your documentation. All right, so SOAP note format, hospital progress notes, again, seem to be the problem area. The subjective area of the visit should change each day. The assessment and plan of care should not be identical from one day to the next. All right, so again, if Sally Sue is in the hospital and I round on that patient Tuesday, Wednesday, Thursday, and I bill a follow-up level two, Tuesday, Wednesday, Thursday, and I pull up all three of those notes and I put them side by side, if nothing changed from Tuesday to Wednesday to Thursday, I may give you credit for Tuesday's visit, but I'm not gonna give you credit for Wednesday and Thursday's visit, okay? Because it doesn't meet medical necessity if you don't change anything. Now, I understand there are some things on the visit note from each, from one day to the next that what, can't, maybe not change, like physical exam, for example. Oh, the patient's no acute distress today and they are tomorrow, great. But again, your subjective, your vitals, your assessment and plan, all that should change from one day to the next. Providers have a medical legal responsibility to ensure the note they sign is complete and accurate. We learned that from the poll question, okay? So here's the problem with some of this stuff. Practices who have medical staff entering information into the medical record are more prone to documentation errors and contradictory information. Here are some examples, and these are some that I have recently seen, okay? So HPI states the patient has been experiencing epigastric pain off and on for the past three months. Review of system denies abdominal pain. Number two, chief complaint states six-month follow-up GERD, but HPI states the patient is here for a new change in bowel symptoms. HPI contradicts the assessment and plan. So the assessment should include conditions that are addressed during the encounter and risk factors that impact decision-making. Do not use a problem list. So I talked about that earlier, okay? I know that, so your patient's record typically has a problem list that you can kind of filter those diagnoses into your visit or you create it, you know? I suggest you create it because that can change from their six-month appointment to their next year, you know, their next follow-up appointment. And again, don't include diagnosis codes that you're not addressing. Number one, it's just more for you to document. And number two, it just looks like we're trying to fluff up the note for a higher level. So keep it pertinent to the chief complaint. Your note should flow. Educate your medical staff. That's one thing that, you know, when we go to practices and they'll say, okay, who do you want to meet with and how long do you want with them? What are we going to talk about? I always say, if we have time, I would like to meet with whoever's in charge of the medical staff, who's in charge of the medical assistants, the nurses, because I go over this information with them. I pull out case studies that I had just reviewed for the practice. And I point it out. I'm like, this is contradictory to this. And this is this. And then stress the importance to them of the information that you're entering in is very, very, very important. It has to be accurate and up-to-date, especially for us, for our specialty. You've got to know every medication that patient has taken. You should know all their vitamins, their herbals, all that stuff. You should know their social history. And again, your chief complaint, and a lot of times this is what I get. When I see that a practice has the chief complaint entered incorrectly a lot, I go back and my first question is, is it filtered from when they make the appointment? You know, so if you're making an appointment and you put reason for visit, well, sometimes they don't update that. And then that gets filtered into the visit note and then nobody changes it. All right, so it looks like from whatever they were here with two years ago, and now they're here for something completely different, that's contradictory information. So someone, before that notice sign, but ultimately it's the provider's responsibility. Clone documentation continues to be a significant problem that creates unnecessary redundancy and at times inaccurate information. Again, most have the ability to copy from one note to another, which causes an explosive amount of data and information that has nothing to do with the current status of the patient. Practices must develop policies designed to address inappropriate use of cloning to minimize noncompliance. All right, so we can't just say, oh yeah, we see that, we do that, and ignore it. All right, if we see it, coders, managers, billers, if you see it, you make it a point to address it and then something needs to be corrected because it's definitely a high risk category for audits. And then you need to recognize that every patient encounter should be unique and must ensure that the health service provided is documented distinctly from all others. Auditors are now trained on the quality, not the quantity of the medical record. They're not gonna get a five page consult from you and go, oh boy, this is a level five, it's so lengthy. No, they're gonna look and see what you documented. Consecutive visits can be requested. Like I said, I can put three in a row and oftentimes that's what we do. We wanna make sure that you're in compliant and you're not cloning everything. Voice recognitions. Okay, so a lot of us use, some of them, the Dragon software, there's other softwares out there. I say train your Dragon because when you first start utilizing that voice recognition software, it doesn't know your voice, it doesn't know your terms and kind of how you speak and all that stuff. So it takes a while. All right, so in the time that it takes, you gotta make sure and review your information and make sure it makes sense. Same with dictation or again, it didn't come through on the voice recognition system and your note comes back and there's blanks all over it. I still see that. You gotta complete it, it doesn't matter if the dictation system or whatever system you're using left it blank, that doesn't mean you leave it blank. You gotta fill in the information. Remember what you sign is a medical legal document and your name is on that claim. So again, I put in this CMS electronic medical record fact sheet and it's not, I have the reference but I didn't put every single thing that they pointed out. I just kind of put more specific to our situations. So EHRs allow medical professionals a seamless approach for coordinating and managing for their patients. They can help reduce paperwork, eliminate duplicate tests, facilitate code assignment for billing. However, it should be noted that recent reports indicate physicians are concerned about systems and operability, documentation overload and untested billing systems. While EHRs can improve healthcare delivery and provider services, they can pose provider challenges. Okay, privacy and security, author identification issues, altering entry dates, cloning, upcoding, coding modifiers. All right, so a couple of these things that I wanted to point out. The first thing, security and privacy issues. Be aware of security features offered and use them while accessing the electronic record. Only authorized entities should be able to access the EHR. There should be secure networks, firewalls, encryptions of data and password protection. The EHR should have a security feature to track all persons accessing and or editing the EHR information, okay? So everybody should have a username and password. Everybody should log off when they leave their stations and create a unique password, not one, two, three, four, one, two, three, four for everything. That's not a good password, okay? And again, if I pull up a, let's say I pull up an office visit and let's say the medical assistant enters some stuff, the nurse enters some stuff, the doctor enters some stuff and Sally and billing goes to print it off, okay? I should be able to go track everyone that was in that medical record and what they did. Okay, that should be a security feature in your EHR. Author identification. Okay, we talked about this. I addressed this a little bit in the split shared visits. Different providers may add information to the same progress notes. When this occur, each provider should be allowed to sign his entry, his or her entry, allowing verification of the amount of work performed and which provider performed the work, okay? Altering entry dates. Your EHR system must have the capability to capture changes to an original entry in the form of addendum correction or deletion. When making changes to the medical record, the date, the time, the author making the change, as well as the reason for the change should be documented. Okay, so this is all kind of a reiteration of what we talked about earlier with Novitas and what they pointed out. Cloning, so again, they address it. Cloning involves copying and pasting previously recorded information from a prior note to a new note. The medical record must contain documentation showing differences and the needs for the patient for each visit or encounter. Simply changing the date without reflecting what happened during the current visit is not allowed. The HHS and OIG indicated that due to the growing issue of cloning, its staffs would be paying close attention to cloned charts. Another one, upcoding, okay? Autoprompts, prefilled templates. So those are there for a guide to help you improve your documentation to help make sure that you get everything in there that's needed. However, if used inappropriately can lead to higher billing and payment. Providers have a medical legal obligation to document and code the service provided. Another big one is coding software, okay? Just because you have built-in coding software in your EHR does not mean the code you selected there is correct or appropriate, okay? The thing with it, and again, this is something that we see when we go on site and they actually allow us into like a test patient just kind of see how they assign levels and whatnot. And most of these systems, once they get to that coding software element, they have to click every little box completely 100% accurate in order for the system to assign the correct level, okay? So just keep that in mind when you're utilizing it. It's a good tool to utilize, but I definitely would have someone do a double check on it. And then we do, again, have at the bottom of this slide, it's called the fact sheet. It's the electronic medical record fact sheet. It's a PDF. You can pull it up, save it to your favorites, reference it as needed. That is it for my EHR talk. And it looks like I'm gonna hand this over to Kathy and she is gonna finish up with the top ASG coding questions.

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