Buried amidst a flurry of OIG recommendations, targets and auditing hoopla are two gems that can help us as chiropractors reduce the possibility of EHR-induced documentation problems.
The news is riddled with stories about the cost of health care “fraud” (current guestimates put this between $75 billion and $250 billion) and are starting to spook even the most jaded of practitioners. Unfortunately, while the widespread growth of EHRs has helped on one hand by enabling chiropractors to efficiently create much better documentation, there is a downside as well. EHR may also enable more widespread problems when used improperly. To this extent, Medicare recently identified the two biggest EHR taboos that could lead to “fraudulent” billing practices.
A common EHR documentation practice is known as “copy-pasting” or “cloning”. Regardless of you’re your particular chiropractic EHR system calls it, cloning allows you to select information from one visit or section in an EHR and replicate it in another section or visit date.
Make no mistake: this is an incredibly useful and time saving tool. Copying repetitive information that has not changed can be much more efficient than having to re-type all the information (or worse yet, accelerate your arthritis by hand-writing it).
However, cloning is easily susceptible to misuse. When chiropractors clone information but do not update it or ensure its accuracy, erroneous data may enter the patient’s medical record. In turn, inappropriate charges may be billed to patients or third-party health care payors. Likewise, improper cloning can facilitate attempts to upcode claims and duplicate or create fraudulent claims.
Here’s a few quick ways to avoid cloning errors:
- Never copy the subjective portion of your daily SOAP note. It’s pretty hard to argue that your notes aren’t cloned when then the last 17 visits state: “Neck pain is improving, Low back pain remains unchanged since the last visit.” Even IF the findings truly had not changed, you’ve got a medical necessity issue on your hands due to the fact that you’ve had 17 visits in a row with virtually no change.
- Avoid copying entire sections from your initial exam note. Face it, you most DC’s don’t perform tests over and over again every visit. While it’s great you took the patient’s blood pressure, temperature or pulse on their initial visit, its likely that they do not have the same exact vitals each and every subsequent visit. And you haven’t re-taken those vitals either. So to act like you did and simply copy every single test you’ve ever done into your daily SOAP note is unnecessary at the least and at the worst, can be potentially fraudulent as you are misrepresenting yourself.
- Never copy “extraneous statements.” On the positive side, recording comments that your patient makes, noting when you refer them to another doctor or reviewing diagnostic testing results are all great ways to improve your documentation. However, when you copy those notes visit to visit, an auditor can smell a cloned note from a mile away. Imagine the ease at which “reviewed MRI results with the patient which revealed L4-5 disc herniation” begins to stand out when seen on your documentation M, W and Friday. Did you really review those MRI films three days in a row? Of course not, you copied the note and forgot to delete that info. Busted.
Another EHR documentation practice that is troublesome is “overdocumentation.” Under this scheme, a chiropractor inserts false or irrelevant documentation into the EHR, creating the appearance of medically necessary information that supports billing at a higher level of service.
Overdocumentation typically occurs in EHR systems that auto-populate fields when using templates built into the system. It may also be seen in EHR programs that generate extensive documentation from the single click of a checkbox. If the chiropractor does not properly edit the documentation and/or gets “click happy” the information may be wildly inaccurate and may lead to inappropriate billing.
Though most DC’s don’t seem to fall into this trap, a growing minority are using EHR to “beef up” their documentation dangerously.
Here are some tips to avoid the bad practice of over-documentation:
- Don’t equate length with quality. For some, a longer note means a better note. Get that thought out of your head because it’s not true at all. I’ve been personally tortured with excessively long notes that say a whole lot of nothing and still missed the mark.
- Test Don’t Teach: there’s no need for you to describe HOW to perform a particular orthopedic test or chiropractic procedure, just do it and record the results. Describing how to perform Kemp’s Test and what will produce a positive finding certainly creates a lengthy and perhaps impressive looking note – until it is read. You are not Charles Dickens getting paid by the word. Keep it simple and give what’s needed. No more, no less.
Final Thoughts & Recommendations
Notice I have intentionally used the word “fraud” in quotes several times in this article. In my experience, few if any of these errors would be prosecuted as fraud. However, the lesser but still unpleasant cousin of fraud is known as “Abuse.” These errors would likely be classified as Abuse which carries penalties of its own: namely, postpayment demands, disciplinary sanctions, providership removal and a whole lot of stress of its own.
Good documentation is a factor of good compliance that most chiropractors know they need, but don’t care to address. Unfortunately, with the onset of more auditing, the impending arrival of ICD-10 and the increasing emphasis on improving the quality of your notes, now is the time to eat that frog and get moving on getting more compliant, creating better notes and protecting your business.
Our Chiropractic Audit Armor program is an interactive compliance training, which includes documentation, coding (including ICD-10), HIPAA compliance and more. You may want to check that out, or continue to take your chances.