1. Medical Documentation and the Electronic Health Record
Chapter 4

2. Learning Objectives Lesson 4
Learning Objectives Lesson 4.1: Medical Documentation and the Electronic Health Record
Identify the most common documents found in the medical record.
Discuss health record systems and list the advantages and disadvantages of an electronic health record system.
Describe the incentive programs established through federal legislation for adoption of electronic health records in physician offices and hospitals.
Define meaningful use and describe the implementation stages.

3. Learning Objectives Lesson 4
Learning Objectives Lesson 4.1: Medical Documentation and the Electronic Health Record (Cont.)
Define the various titles of physicians as they relate to health record documentation.
Explain the reasons that legible documentation is required.
List the documentation guidelines for medical services and describe common errors found in medical records.
Identify the components required for documentation of an evaluation and management service based on Medicare guidelines.

4. Learning Objectives Lesson 4
Learning Objectives Lesson 4.1: Medical Documentation and the Electronic Health Record (Cont.)
Define common terminology related to medical, diagnostic, and surgical services.
Abstract information from the medical record to complete a life or health insurance application.
Describe the difference between prospective and retrospective review of records.
Respond appropriately to the subpoena of a witness and records.

5. Learning Objectives Lesson 4
Learning Objectives Lesson 4.1: Medical Documentation and the Electronic Health Record (Cont.)
Identify principles for retention of health records.
Formulate a procedure for termination of a case.
Discuss in-depth documentation requirements for evaluation and management services.

6. The Documentation Process
Documentation is “a chronologic detailed recording of pertinent facts and observations about a patient’s health as seen in chart notes and medical reports.”
Anything in the patient record is considered “documentation.”

7. The Documentation Process (Cont.)
Common medical office documents
Patient registration (demographic information)
Medication record
History and physical examination notes or report
Progress or chart notes
Consultation reports
Imaging and x-ray reports
Laboratory reports
Immunization record
Consent and authorization forms
Operative report
Pathology report
Health record: written or graphic information documenting facts and events during the rendering of patient care.
These forms may be kept on paper, on microfilm, or electronically, depending on the system used in the medical office.
A hospital record would also include an attending physician’s orders, date of admission, hospital stay dates, discharge date, and discharge summary.

8. Health Record Systems Problem-oriented record (POR) system
Documents are flow sheets, charts, graphs
Source-oriented record (SOR) system
Documents stored in sections
Electronic health record (HER) system
Collection of medical information about a patient
Difference between EHR and electronic medical record (EMR)
A POR system allows a physician to quickly locate information and compare evaluations.
An SOR system organizes documents into sections, not by data.
The EHR is a collection of medical information about the past, present, and future of a patient that resides in a centralized electronic system. This system receives, stores, transmits, retrieves, and links data from many different information systems. The EMR is an individual physician’s personal medical record on a patient. Everything contained in the EMR is contained in the EHR.

9. Electronic Health Records
Advantages of the EHR
Less physical space required
Automatic data capture
Available data for other purposes
Easier authentication
Automatic insurance verification
Automated/computer-assisted coding
Batch transmittal of insurance claims
Complete online management
Computer systems can make data from medical records available for other purposes, to help develop protocols and critical pathways for disease management.
An EHR system holds information in a centralized location, giving access to all patient data quickly.
Disadvantages of the EHR include startup costs, usability, and learning curves for the employees. Also, confidentiality and security issues are viable concerns.

10. Incentive Programs for Adoption of Electronic Health Records
Physician Quality Reporting System (PQRS) Incentive Program
Electronic Prescribing (eRx) Incentive Program
Medicare and Medicaid EHR incentive programs
Meaningful use (MU)
PQRS was one of the initial incentive programs resulting from the Tax Relief and Health Care Act of 2006 (TRHCA). The program started in 2011.
Beginning in 2015, eligible providers who do not report PQRS measures satisfactorily will be subject to payment adjustments equal to 1.5% of their Medicare Physician Fee Schedule (MPFS).
The e-prescribing incentive program started in 2011 and ended in January of 2014; physicians who do not successfully e-prescribe will be penalized at a rate of 2.0% throughout 2014 and 2015.
Under the Medicare incentive program, eligible providers (EPs) that began participation in this program prior to 2013 had the opportunity to earn incentive payments for up to 5 years.
Under the Medicaid incentive program, EPs have the opportunity to earn incentive programs for up to 6 years.

11. Meaningful Use Stage 1: 2011-2013 Stage 2: 2014-2015 Stage 3: 2016
Focused on data capture and sharing
Stage 2:
Focused on advance clinical processes
Stage 3: 2016
Focuses on improved outcomes
Meaningful use (MU) involves demonstrating that the health care organization has the capabilities and processes in place so that the provider is actively using certified EHR technology to:
Improve quality of care, patient safety, and efficiencies in health care, as well as reduce health disparities
Engage patients and family in management of their care
Improve care coordination and the general public health
Maintain privacy and security of patient health information

12. Documenters Types of physicians Attending physician
Consulting physician
Non-physician practitioner (NPP)
Ordering physician
Primary care physician (PCP)
Referring physician
Resident physician
Teaching physician
Treating or performing physician
Discuss each physician type.

13. Legible Documentation
Avoidance of denied or delayed payments by insurance carriers investigating the medical necessity of services
Enforcement of medical record-keeping rules by insurance carriers requiring accurate documentation that supports procedure and diagnostic codes
Subpoena of medical records by state investigators or the court for review
Defense of a professional liability claim
Execution of the physician’s written instructions by a patient’s caregiver
Why does documentation have to be legible? (To prevent problems with insurance claims and to comply with laws and guidelines related to the medical documentation)

14. Common Documentation Errors
Medication lists are not updated.
Incorrect dosages of prescription medications are documented.
Duplicate prescriptions are documented for brand and generic medications.
Over-the-counter medications the patient is taking are not documented.
Allergies are not documented.
Lab information is missing or not updated.
Inaccuracies in diagnosis are made.
When health care providers put patient care first, documentation is a process that follows and is oftentimes dashed off too quickly.

15. Medical Necessity
Payment may be delayed, downcoded, or denied if the medical necessity of a treatment is questioned.
Medical necessity is a criterion used by insurance companies, as well as Medicare.
Medical treatments must be done in accordance with standards of good medical practice and the proper level of care.
Insurers differ on the definition of medical necessity.
Chapter 12 discusses more about the Advance Beneficiary Notice of Noncoverage (ABN).

16. Legalities of Health Record Billing Patterns
Billing patterns causing possible audit
Billing intentionally for unnecessary services
Billing incorrectly for services of physician extenders
Billing for diagnostic tests without a separate report in the medical record
Changing dates of service on insurance claims to comply with policy coverage dates
Waiving copayments or deductibles, or allowing other illegal discounts
Medicare fiscal intermediaries have “walk-in rights” that they may invoke to conduct documentation reviews, audits, or evaluations.
Explain which of these problems are also considered insurance fraud. (Falsifying information of any type on a medical record would be considered fraud. Therefore, billing for tests not in the record or changing dates of service on the claim would be considered fraud.)

17. Legalities of Health Record Billing Patterns (Cont.)
Billing patterns causing possible audit
Ordering excessive diagnostic tests
Using two different provider names to bill the same service for the same patient
Misusing provider identification numbers, resulting in incorrect billing
Using improper modifiers for financial gain
Failing to return overpayments made by the Medicare program
All of these patterns are considered fraud or abuse.

18. Documentation Terminology
Evaluation and management (E/M) terminology
New versus established patient
Consultation
Referral
Concurrent care
Continuity of care
Critical care
Emergency care
Counseling
Reimbursement for a consultation is significantly more than for an equivalent office visit.
What is concurrent care? (The provision of similar services [e.g., hospital visits] to the same patient by more than one physician on the same day)
What is continuity of care? (When a physician sees a patient who has received treatment for a condition and is referred by the previous doctor for treatment of the same condition)
Critical care usually takes place in the emergency department or a critical care unit of a hospital.

19. Documentation Terminology (Cont.)
New versus established patients
Figure 4-2 shows a decision tree for new versus established patient when selecting a current procedural terminology (CPT) evaluation and management code.
What is the difference between a new patient and an established patient? (A new patient has not received services from the physician [or a physician of the same specialty in the same practice] within the past 3 years. An established patient has received services from the physician [or a physician of the same specialty in the same practice] within the past 3 years.)
Use this decision tree (Figure 4-2) to determine whether a patient is new or established.

20. Diagnostic Terminology and Abbreviations
Most physicians use abbreviations in medical documentation.
Eponyms should not be used if another medical term applies.
Proper documentation guidelines should always be followed.
Documentation should be as specific as possible.
The American Hospital Association’s (AHA’s) official policy is that “abbreviations should be totally eliminated from the more vital sections of the health record.” Many physicians are not aware of this policy and may continue to use abbreviations throughout the documentation.
What is an eponym? (The name of a disease, anatomic structure, operation, or procedure, usually derived from the name of a place where it first occurred or a person who discovered or first described it)
Define acute and chronic. (Acute: a condition that runs a short but relatively severe course. Chronic: a condition persisting over a longer period.)

21. Directional Terms
Figure 4-3, A shows the four quadrants of the abdomen.
Have students name organs contained in each region. (RUQ [right upper quadrant]: liver [right lobe], gallbladder, pancreas [part], small/large intestines [part]; LUQ [left upper quadrant]: liver [left lobe], stomach, spleen, pancreas [part], small/large intestines [part]; RLQ [right lower quadrant]: small/large intestines, right ovary, right uterine [Fallopian] tube, appendix, right ureter; LLQ [left lower quadrant]: small/large intestines [part], left ovary, left uterine [Fallopian] tube, left ureter)
From Herlihy B, Maebius NK: The human body in health and illness, ed 4, St Louis, 2011, Elsevier.

22. Directional Terms Figure 4-3, B shows the nine regions of the abdomen.
How do these nine regions relate to the four quadrants? (The nine regions are more specific and are part of the four quadrants.)
From Herlihy B, Maebius NK: The human body in health and illness, ed 4, St Louis, 2011, Elsevier.

23. Surgical Terminology Preoperative versus postoperative
Simple/intermediate/complex
Undermining
Take down
Lysis of adhesions
Position
Approach
Preoperative is the period before a surgical procedure, and postoperative is the period after the surgical procedure.
Surgical procedures of the integumentary system are listed as simple, intermediate, or complex.
In a surgical report, explain what undermining means. (Cut in a horizontal fashion)
Define take down. (To take apart)
Explain what lysis of adhesions means. (Destruction of scar tissue)
Discuss why coders should care about position or approach in surgical reports. (Codes can be different depending on the position or approach documented in the surgical report.)
See Table 4-1 for ICD-10-PCS terminology used in coding procedures.

24. Abstracting from Medical Records
Abstraction from medical records may be required for three situations:
To complete insurance claim forms
When sending a letter to justify a health insurance claim form after professional services are rendered
When a patient applies for life, mortgage, or health insurance
In some situations, it is preferable to submit a narrative report dictated by the physician instead of completing the form.
It may be necessary to attach a copy of an operative, pathology, laboratory, or radiology report and an electrocardiogram tracing.

25. Internal Reviews Prospective Retrospective Prebilling audit/review
Postbilling audit/review
Discuss why internal reviews are important to a medical practice. (Internal reviews may help prevent external audits and may catch errors before the billing cycle is complete. This will save the practice time, money, and possible penalties in the long run.)
Explain which type of internal review is done before billing and why. (Prospective review: Stage One—to verify that completed encounter forms match patients seen according to the appointment schedule and have been posted on the day sheet; Stage Two—to verify that all procedures or services and diagnoses listed on the encounter form match data on the insurance claim form)
Explain which type of internal review is done after billing and why. (Retrospective review: to determine whether there is a lack of documentation)

26. Subpoena Process
Issued by a judge to obtain witness statements or records
May not require an appearance in person
Never accept a subpoena or give records without the physician’s prior authorization.
What is a subpoena? (Subpoena means “under penalty.” It also refers to the writ that commands a witness to appear at a trial or other proceeding and give testimony.)
What is subpoena duces tecum? (Literally means “in his possession.” This is a subpoena that requires the appearance of a witness with his or her records.)
If needed for a trial, records must be kept secure. They should be mailed via certified mail (or other secure method) with return receipt.
Always comply fully with a subpoena or any instructions during a court proceeding.

27. Retention of Records Table 4-2 shows the records retention schedule.
How is a record retention schedule used? (Once records are kept for the appropriate amount of time, they can be disposed of. This could mean shredding, conversion to microfilm, or disposal by a professional company.)
Are EHRs on the same retention schedule as paper records? (EHRs may have different retention periods, depending on state law. Electronic files may also be easier to keep in the medical office, since they are easier to store.)
Discuss whether EMRs are more or less safe than paper records. (Electronic records can be more easily deleted and altered than paper records. Additional answers will vary.)

28. Termination of Case Example of a form letter
Figure 4-6 is an example of letter of withdrawal from a case that is typed in modified block style with closed punctuation and special notations (placement of parts of letter).
Explain when a physician might send this type of letter. (A physician may wish to withdraw formally from further care of a patient. This could be because of patient noncompliance, either in treatment or payment.)
Is this type of letter necessary? Explain why or why not. (This letter is necessary to prove the physician did not abandon the patient’s case.)

29. Prevention of Legal Problems
Keep patient information confidential.
Report all physician activity that is illegal or unethical.
Be aware of any hazards that may cause injury.
Do not discuss other physicians with patients.
Take the time to explain fees to patients.
Are these guidelines necessary? Explain why or why not. (Yes. An insurance billing specialist must be aware of legal issues in the medical practice and must follow guidelines to limit the likelihood of a lawsuit or external audit.)
See Box 4-1.

30. Prevention of Legal Problems (Cont.)
Be sure documentation corresponds with insurance billing.
Be aware of all changes in insurance program guidelines.
Always obtain written consent for records release.
Obtain physician authorization before turning an account over for collection.
Always act in a courteous and professional manner.
Ask students what the consequences would be if these guidelines were not considered. (External audit, sanctions, etc. Answers will vary.)
See Box 4-1.

31. Documentation Guidelines for Evaluation and Management Services
Health record should be accurate, complete (detailed), and legible.
The documentation of each patient encounter should be complete.
Appropriate health risk factors should be identified.
The confidentiality of the health record should be fully maintained.
For office visits, the majority of physicians use SOAP documentation.
The documentation of each patient encounter should include or provide reference to the following: chief complaint, relevant history, examination, findings, prior diagnostic test results, assessment, clinical impression, or diagnosis, plan of care, and date and legible identity of the health care professional.

32. Documentation Guidelines for Evaluation and Management Services (Cont
Figure 4-10: In a paper-based system, explanation of the acronym SOAP used as a format for progress notes defining subjective and objective information, the assessment, and the treatment plan.
Some physicians choose to document using a narrative or more detailed/descriptive style, but the majority of physicians in a paper-based system use the SOAP style of documentation.

33. Audit Point System
A point system is used while reviewing a patient’s health record during the performance of an audit.
It is possible that the auditor may shift the points from the history of present illness (HPI) to those required for the review of the body systems.
HMOs, PPOs, and all private carriers have the right to claim refunds in the event of an accidental (or intentional) miscoding.
If it was not documented, then it was not performed.

34. Documentation of History
Chief complaint (CC)
History of present illness (HPI)
Review of systems (ROS)
Past, family, or social history (PFSH)
The extent of the history depends on the clinical judgment and the nature of the presenting problem.

35. Documentation of History (Cont.)
Figure 4-13, A: Documentation from a health record highlighting elements required for the history.
Using this sample, have students identify whether each piece of information is considered the chief complaint; a history of the present illness; past, family, and social histories; or a review of symptoms.

36. Documentation of History (Cont.)
Figure 4-12, B: Review or audit sheet Section I with check marks and circled elements shows how the history in the example is declared as detailed. This shows two of three history components (arrow) used for the purpose of determining the assignment of a procedure code at the appropriate level of service.
Each history item identified in the medical record should be taken into consideration when filling out the History section of the review/audit form. Once all items are accounted for, elements for each history component can be determined. Based on these elements, the level of history can be determined.

37. Documentation of Examination
Physical examination
Organ systems/body areas
Elements of examination
Types of physical examination
Problem focused (PF)
Expanded problem focused (EPF)
Detailed (D)
Comprehensive (C)
See Figures 4-15 through 4-18 for examples of a review/audit worksheet.

38. Documentation of Medical Decision Making
Medical decision making (MDM) is a health care management process done after performing a history and physical examination on a patient that results in a plan of treatment.
Based on establishing one or more diagnoses and/or selecting a management or treatment option
Morbidity versus mortality
Morbidity is a diseased condition or state, whereas mortality has to do with the number of deaths that occur in a given time or place.
To conclude the internal review of a patient’s health record, a level must be determined by the health care provider from one of four types of MDM: straightforward (SF), low complexity (LC), moderate complexity (MC), and high complexity (HC).

39. Questions?