How Does Your Electronic Record Measure Up Under Audit? 

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As a result of an interview that I did with Kathleen Schaum in the latest Business Briefs on electronic signatures, I felt the need to convey to our readers some of the issues I have seen when auditing electronic health records (EHRs) specifically. I am hoping this article will serve as a guide to check into how your electronic records will be reviewed.
 
First and foremost, do yourself a favor and actually print out a record of what the insurance carrier will see if documentation has been requested to pay for a service. You may be surprised at what you see! I make this suggestion as all too often, physicians are trained on the system, but were not involved in setting up the templates and/or information that needs to be captured.
 
To begin, I have provided an excerpt from the Program Integrity Manual, Chapter 3, below.¹ The link is contained in the interview article. I thought it would be helpful to cite the Medicare Program Integrity Manual for their view on signatures. While facilities may be aware of Joint Commission and state regulations, they may not be familiar with the Medicare requirements.

Electronic Signatures: Providers using electronic systems need to recognize that there is a potential for misuse or abuse with alternate signature methods. For example, providers need a system and software products that are protected against modification, etc., and should apply adequate administrative procedures that correspond to recognized standards and laws. The individual whose name is on the alternate signature method and the provider bear the responsibility for the authenticity of the information for which an attestation has been provided. Physicians are encouraged to check with their attorneys and malpractice insurers concerning the use of alternative signature methods.¹
 
Amendments, Corrections and Delayed Entries in Medical Documentation: All services provided to beneficiaries are expected to be documented in the medical record at the time they are rendered. Occasionally, certain entries related to services provided are not properly documented. In this event, the documentation will need to be amended, corrected, or entered after rendering the service. When making review determinations the MACs, CERT, Recovery Auditors, SMRC and UPICs shall consider all submitted entries that comply with the widely accepted Recordkeeping Principles described in section B below. The MACs, CERT, Recovery Auditors, SMRC and UPICs shall NOT consider any entries that do not comply with the principles listed in section B below, even if such exclusion would lead to a claim denial. For example, they shall not consider undated or unsigned entries handwritten in the margin of a document. Instead, they shall exclude these entries from consideration.¹
 
Section B. Recordkeeping Principles. Regardless of whether a documentation submission originates from a paper record or an electronic health record, documents submitted to MACs, CERT, Recovery Auditors, SMRC and UPICs containing amendments, corrections or addenda must:
1. Clearly and permanently identify any amendment, correction or delayed entry as such
2. Clearly indicate the date and author of any amendment, correction or delayed entry, and
3. Clearly identify all original content, without deletion.¹

Hopefully this citation will give a good reference regarding signatures as well as guidance for editing, late entries, and any amendments made to electronic records. Now that we have addressed the electronic recordkeeping, I want to turn our attention to some of the common documentation problems that I have seen in electronic records.

Problems With the EHR

There may be plenty of excuses as to why required elements are not contained in the record. I have heard “The template doe not ask for it,” “It is the system’s fault, not mine,” “Maybe our training was inadequate,” and so forth. Please be advised that all of these seem like they are good excuses; however, it does not release you from the responsibility of having complete, accurate and compliant documentation in your records.
 
I encourage all to have a thorough understanding of their EHR. Review your templates to ensure there is a place for your documentation in order to meet requirements. If there is not, have a conversation with the health information management director (medical records) to see what could be done to improve the templates with your EHR vendor. I have included some items to check for in your records to ensure there is an adequate spot to include the required information in the record.
 
First, let’s start with the History and Physical for wound care. Please locate the following documentation in your record:
 
1.    Compete wound history including:
       A. Duration
       B. Underlying cause
       C. Description of percentage of granulation vs. percentage of necrotic tissue (should equal 100%)
       D. Referral and notes to document conservative treatment prior to cellular- and tissue-based product (CTP) application if applicable. 
       E. Specify conventional therapy dates and results of any previous treatment
       F.  Smoking history if any
       G. History of the wound treatments, and progress made between visits for each wound

2.    Any underlying disease processes or status that could affect wound healing such as paraplegia, diabetes, vascular issues, etc.
 
3.    Describe each wound to include:
       A. Specific anatomic site for each wound. Is the wound location on your exam? 
       B. Does your physical exam always say “normal” when there is a wound?
       C. Wound characteristics such as diameter, depth, undermining or tunneling, color, presence of exudate or necrotic tissue.
       D. Patient goals and response to previous treatment.
       E. Ensure wounds are identified consistently over multiple visits.

Now, let’s turn our attention to procedures in the record. Please verify that your records contain the following information:

1.    Does your template have a specific place to document any procedures performed?
       A. Pre- and post-procedure measurements. What does it mean if they are both the same? How does that justify what was done?
       B. Document medical necessity of treatment.
       C. Must state exact tissue that was removed from wound, and instruments used. NOTE: Depth of tissue removed not what you can see. If only slough and necrotic tissue are removed, it is a 97597. The term sharp does not necessarily mean surgical debridement, nor does the fact that a scalpel was used. Is debridement documented to say down to healthy bleeding tissue?
       D. For CTPs, documentation must describe how every cm2 is used or discarded.

2.    Documentation must show why you selected a product for the patient. 
       A. What is the rationale for continued use of a product? 
       B. Is there evidence of infection around the wound like cellulitis/osteomyelitis? NOTE: CTPs are contraindicated in the presence of infection.
       C. Documentation should be showing that wound is shrinking, not growing! If product is not working, what are you switching to and why? Rationale cannot always be to “progress to wound healing/closure”
 
Last, here are recommendations for reviewing what your electronic record looks like when it is printed out:

1. Highly recommended to go through your electronic record data screens and compare to the output. 
2. Sometimes programming can lead to unfortunate documentation errors when the user is not familiar with how the screens flow, and how the information would look like on a printed record.
3. The provider needs to clearly understand that regardless of the electronic record vendor it is the providers responsibility for the information represented in the record.
4. Can you locate the plan of care in your record and is it updated each visit?
5. Can you follow the progress of each wound separately in the record?
6. Can you include pictures and/or drawings of the wound in the record?

There can be many surprises after doing this type of review. These are some of the most common elements missing from electronic records in my experience … there may be more! Hopefully, what I have provided to you will assist in the evaluation of your templates to ensure that the detailed information required is able to be reflected in your EHR. Be sure to print your record for this type of evaluation and make any adjustments necessary through your EHR vendor or work with the health information management department to improve your templates. Avoid getting payments denied due to lack of documentation in your EHR!
 
Donna Cartwright is senior director of health policy and reimbursement at Integra LifeSciences Corp., Plainsboro, NJ. She is an AHIMA-approved ICD-10-CM/PCS trainer, and she has been designated as a fellow of the American Health Information Management Association.

Reference

1. Centers for Medicare and Medicaid Services. Medicare Program Integrity Manual. Chapter 3 - Verifying Potential Errors and Taking Corrective Actions. Published May 25, 2023.