Digitizing your medical records is an effective way to improve practice workflow and reduce paper. But EMRs can also increase your risk of a documentation audit, unless you use their record keeping and automation features properly. Here are three risk areas that any orthopaedist who is evaluating, or using, EMR should be concerned with.

Risk #1: Poorly Designed Visit Templates

A critical component of successful EMR implementation is customizing the vendor’s visit templates. But many surgeons skip or abdicate this step. A large spine practice we worked with passed the task off to its non-clinical Practice Administrator. It should have been no surprise that the surgeons found the templates useless.

Why is customization so important? Standard visit templates create multi-page notes that don’t necessarily document what you did. The exam template for a spine surgeon bears little resemblance to what a foot and ankle surgeon needs. Templates are the most critical step toward making sure your documentation is right; bypass their customization at your own peril.

Vendors often aren’t much help in this area. Better to print an ICD-9 frequency report to identify the conditions you see and treat most often, and create a template for each of them in your new system.

 Risk #2: ‘Cloning’ 

Touted as a time-saver, EMRs automatically ‘pull forward’ the History of Present Illness (HPI) documentation from each previous patient encounter. That’s ok as long as you review and update the HPI for the current encounter. But when surgeons get busy, this step can be forgotten.

Letting the EMR pull the previous history into an auto-generated form without reviewing it is risky because E&M documentation guidelines state that each record must stand on its own. You’ve got to pay close attention to what is being pulled forward because the patient problem could be completely different. Cloning also creates a verbose chart note that contains rote responses, which don’t necessarily call out pertinent positives.

How do you deal with cloning? Make sure you factor into your workflow the essential step of reviewing HPI at every visit, and making updates to the documentation that the EMR has ‘pulled forward.’

 Risk #3: Coding Calculators

 Don’t assume the coding calculator algorithm in your EMR is generating the correct code. Some of these put practices at risk by suggesting code levels that don’t match what was documented.

A seven-surgeon orthopaedic group in Minnesota noticed an increased number of high level E&M codes after their EMR go-live. The practice conducted an internal audit and realized the algorithm on the medical decision-making component was incorrect. Luckily, they had a savvy billing office that picked up on the error and overrode it with the correct, lower level E&M code.

Orthopaedists should be concerned about this. Medicare recently said that, in the past three years, it processed a greater percentage of 99214 and 99215 code in almost all specialties. According to Part B News, the ‘proliferation’ of EHRs ‘allows easier documentation,’ thereby justifying higher E&M levels. It’s likely Medicare may target these code levels for an audit sooner rather than later.

What to do? Ask the vendor to create and code few chart notes using some of your current documentation, and verify that the codes ‘calculated’ match what you billed.

 The American Academy of Orthopaedic Surgeons’ June issue of AAOSNow features interviews with nationally-recognized auditorsand coding educators discussing these documentation risks and how to deal with them. Heeding this advice can reduce your audit risk exposure and improve EMR success.

Cheryl Toth is a consultant with KarenZupko & Associates, Inc. and wrote this article as a guest author for OrthopaedicLIST.com.  She helps practices implement and adopt technology in order to work smarter and more efficiently.  KarenZupko & Associates, Inc. is a national leader at providing coding and documentation audits, training, and consultations.