For billers, coders, and practice administrators, EHR software can sometimes feel like the ‘Twilight Zone’ of revenue cycle management. I’ve heard frustrated RCM professionals describe their practice’s EHR system as a mysterious black box where coding errors happen for reasons that are hard to trace or understand. Small EHR glitches are sometimes hard to see before they become big, horrible RCM problems—or even the focus of a documentation audit. In extreme cases, EHR glitches, flaws, and user errors actually make providers more vulnerable to fraud risks.
Why? Reimbursement simply isn’t the raison d’être for EHR.
Developers have focused on mostly on clinicians when designing medical records software, according to Angela Jordan, CPC, COBGC, AAPC Fellow and senior managing consultant at SCBI. That clinical focus made sense: EHR developers wanted their software to work well for patient care and they knew that physician owners were making the purchase decisions. Most EHR companies didn’t understand the complexities of medical reimbursement and many didn’t even think to ask, Jordan told attendees at the American Academy of Professional Coders’ regional conference in Salt Lake City earlier this year.
It’s only recently that EHR companies have begun to hire coders and other RCM experts to help them design software that integrates well with practice management systems and works just as well for RCM as it does for the clinic, Jordan says. As development continues, good EHR systems will work better in clinical settings and in the back office. But what can we do in the meantime?
Here’s the good news. If you’re someone in the practice who focuses on RCM, the EHR doesn’t have to be a ‘stranger thing’ for you. It can become a familiar thing if you make it part of your job to understand how it works. Even better, your EHR can become your powerful ally for correct coding and billing (and cutting-edge practice management) if you learn how to master it.
Ready to shed some light on the inner workings of your EHR? Let’s get to know our EHR better so you can improve RCM and make your practice a better place.
Before you dig into your software to uncover EHR glitches that could be working against your practice, make sure you clearly understand guidelines from your Medicare carrier and other major payers.
Carrier guidelines aren’t all the same, Jordan stresses. But despite some differences, most payers agree on some general principles. Be wary—very wary—if your EHR system has one or more of the following characteristics:
Some EHR systems “auto-populate” parts of the medical record with information that is not specific to the patient or the encounter, especially in the HPI section, Jordan warns. Payers don’t like what this “auto-populate” feature does to medical records, so it could come back to bite you in a documentation audit. As an example of one Medicare carrier’s position on auto-populate, Jordan offers this statement from Noridian:
“Auto-populated paragraphs provide useful information such as the etiology, standards of practice, and general goals of a particular diagnosis. However, they are generalization and do not support medically necessary information that correlates to the management of a particular patient … Credit cannot be granted for information that is not patient-specific and date-of-service-specific.”
Overrides that allow backdating
Some EHRs still allow clinicians to backdate records. If your EHR still does that, Jordan recommends that you ask your vendor to prevent backdating so that any auditor can clearly see when the record originated, when corrections were made, and by whom. If clinicians need to go back to a medical record to add more information, they need to do an addendum, Jordan stressed. The record should show the date new information was added, who added it, and the reason for the addition.
Electronic signatures that lack provider credentials
Your practice likely has ophthalmologists, optometrists, techs, and scribes all working in the EHR on the clinical side. Carrier and payer guidelines vary regarding which clinicians can perform, document, and sign off on each part—so it’s crucial that electronic signatures also list credentials so that internal and external auditors can tell who was qualified to do what.
Some EHR companies set up electronic signatures during implementation and tell the practice it can add credentials later, Jordan warns. But credentials in electronic signatures aren’t a matter of choice, and this step is easily forgotten during the difficult work of going live. To prevent problems later, insist that electronic signatures include credentials during set-up.
Prevent These 3 User Errors
Have you focused so much on your EHR and practice management software that you’re ignoring the human factor?
Sometimes, practices spend so much money on the technology itself that they skimp on training for their front office, clinicians, and back office, Jordan observes. As the practice adapts to and uses HIT over a period of time, clinicians and staff sometimes discover adjustments and hacks that they share informally among themselves. Not all of these user adjustments are good, and some are so bad they could cause your practice lots of headaches during a documentation audit. Here are three bad EHR habits to watch out for and correct as part of your clinical documentation improvement (CDI) efforts:
Poor documentation for time-based codes
Some EHRs have pop-ups designed to help providers estimate time. But if your clinicians select only the time, the result can be a progress note with no documentation in it. Your documentation templates for time-based codes should remind providers to mention topics covered during counseling in the note.
Copy and Paste
An EHR’s copy and paste function “provides the ability to re-use all or parts of detailed narrative information and is seen by physicians and EHR system users as a valuable and time saving tool,” AHIMA explains. Some systems call this function “make me the author” or “carry forward.” Without appropriate clinician training and system controls, however, the copy and paste function can result in identical documentation, cloning, or medical plagiarism that can compromise a practice during a documentation audit.
Some doctors have taken to inserting disclaimers into their notes such as “I dictated this in Dragon so please disregard any errors,” Jordan says. Disclaimers like this basically say, “I know I made mistakes and didn’t proofread, but just ignore them.” Payers and auditors do not like this.
Tried-and-True EHR Training Moves for New Staff
It’s always challenge to onboard new staff, but EHR has made the learning curve even steeper.
“Today, new employees must face the looming EHR giant of new computer systems, software, online portals, and workflow processes,” observes Anndrea Grant, COMT, OSC, lead clinical technician at Northwest Eye Clinic in Washington State. Even if new hires have previous experience working in an eye care practice, odds are your EHR is new to them. Make sure your ramp-up plan for new hires includes “an extensive training period to become proficient in the new EHR they will be using,” Grant says.
Eyes Open: Many EHR-related RCM problems originate from clinician mistakes, so it’s important to make sure new clinicians are comfortable and confident on your EHR. Think of this training time as an investment in your clinical documentation improvement (CDI) effort.
Train new hires on simple data entry first, like entering “pre-visit” history, Grant advises. “This helps the new hire become familiar with the EHR system and build their medical knowledge at the same time.”
Have new hires act as scribes for a designated trainer when they begin, Grant suggests. Typically, new hires in training get only a “watch and learn” experience. They are still limited in what they can do in the EHR by themselves. But Grant encourages practices to take advantage of that time by putting new hires to work as “scribes for the trainer, entering all the patient information into the EHR as the trainer performs the patient workup.”