April 2, 2007

EMR and the Coder: The Dark Side of the Force
By Judy Sturgeon, CCS
For The Record
Vol. 19 No. 7 P. 6

Last month’s “Coding Corner” featured a review of some major advantages to be gained by a facility that converts from paper medical records to an electronic (or digital) format. As with so many other changes we deal with on a personal or professional level, it is often necessary to manage negative aspects as well. Not all problems are avoidable, but if we at least understand what the issues are, we will be prepared to minimize their effects.

The ability of the electronic chart to copy patient history from encounter to encounter is certainly one of its major selling points. This feature cuts out the repetitiveness of physically looking up a patient’s history and copying it all down again each time he or she returns for additional care. This “copy-paste” function can be easily overused, and subsequently misused as well.

A misdiagnosis can be auto-copied from encounter to encounter, and be overlooked because the condition appears in the chart effortlessly. If the caregiver should become complacent about this digital convenience and not validate each diagnosis or condition that is carried over from previous encounters, the accuracy of the data being coded and reported is at risk. If a condition is “history only,” but the physician allows it to be copied in the encounter as if it were a current problem affecting care, noncompliance with coding and billing rules could result. The danger does not end here; the patient’s health could be affected if treatment, based on the duplicated medical or pharmaceutical misinformation, is administered.

Data reporting isn’t only an issue of skewing a graph somewhere in a government archive. When the provider’s payment contract is based on reported diagnosis and procedure codes, accuracy is critical whether the issue is medical necessity validation for treatment and payment rendered or DRG payments (diagnosis-related group for hospital inpatient). In either instance, permitting a software system to create coding and billing errors may put the provider at risk for abuse penalties. Because the coder is always directed to query the physician when there is any doubt about the validity of the documentation being reviewed, the coder will share the burden created by the copy-paste conundrum. The ability is too convenient and too much of a time-saver to disregard, but users must exercise caution as well as diligence when applying this function.

Formatted phrases pose another “simplicity” threat to accurate patient documentation. This capability allows the physician or service to preformat phrases based on key word entries. An example might be a common phrase such as “the patient was discharged home in good condition, with instructions for follow-up with primary care physician in a week.”

If the electronic medical record (EMR) is set up to automatically type this entire phrase after it recognizes “the patient was discharged home,” there can be fiscal consequences as well as information errors. If the hospital inpatient is actually discharged home with home health, and the doctor doesn’t catch the automatic phrase and correct it, chances are significant that the DRG will be affected by the discharge disposition because many Medicare transfer DRGs adjust payment depending on additional postdischarge care received by the patient. In this example, as in the copy-paste situation, the coder can be responsible for determining whether the physician was correct, even though the physician is still responsible for the initial documentation error.

Drop boxes for diagnoses and procedures, with their associated codes already attached, are an attractive function of many EMR products. A software encoder product that is embedded in the EMR can offer a preprogrammed favorites list as the physician types the first few letters of a word or phrase. What apparently results is a tidy, precoded summary of all the patient’s diagnoses and procedures.

If I had to choose a single aspect of the inpatient EMR that strikes terror into my heart, it would have to be the drop-box coding function. I have mental images of bypassed Correct Coding Initiative edits, billions of dollars in unbundled procedure claims, incomplete and invalid codes deleted from claim interfaces, and a case mix index graph that resembles the trajectory of Britney Spears’ career.

Certainly this is a greatly magnified worst-case scenario, but let’s look at the components and their possible causes. The overall concerns are valid and twofold. First, the sophistication of the EMR’s encoder product is of critical value. Second, the coding competency of the person selecting the codes is essential to both financial compliance and accurate HIM.

If the EMR vendor’s encoder is not kept up to date with each code and DRG change as it becomes effective, claims will be submitted with invalid codes that can be dropped by the receiving billing interfaces. (Your claim won’t get paid correctly.) If the physician selecting the code chooses the first one that looks close from a favorites list instead of reviewing all the codes in the category to select the most correct, it can influence:
• whether the encounter justifies medical necessity for the service;

• what the DRG will be for a hospital inpatient claim;

• what the total charges will be for both inpatient and outpatient claims;

• compliance with federal False Claims Act and related fraud/abuse impact;

• repeated errors that will change the facility case mix, which, in turn, will affect the payments to the facility for years to come; and did I mention state and federal compliance?

How many physicians will routinely select every diagnosis (with their respective codes) that comes to mind? Conversely, how many only document those specific to their service? Either scenario is a compliance, financial, and data disaster waiting to happen.

The professional coder knows the regulations for when to first sequence a cause as opposed to an effect. Coders keep up to date with official coding rules and will review all the codes when selecting the correct—rather than the closest and easiest—one. It is also the coding specialists who are able to accurately summarize all codes that affect care on any encounter; to exclude those that are prohibited from being used in any particular medical circumstance; and to know when a symptom must be coded and when it is prohibited from being coded. It is they who best understand the need for procedure code modifiers that may not even be offered by the EMR encoder, and the difference between coding rules for inpatient vs. outpatient cases.

As we embrace the convenience and speed that emerging technology offers, coders will still need to be on the alert to protect coding issues in EMR development and application. Coding managers will not only need continuing input from their staff after the electronic chart is up and running, they will also need to be proactive when the product is being set up. Remember to include coders in evaluation of the encoding product offered by the vendor. If there are limits to its accuracy or functionality—and you are unable to obtain one that is more efficient—you will at least be informed prior to any financial or compliance snafus. Forewarned is forearmed: Be prepared with workarounds as possible and with alternate processes as needed.

How do you ensure that the digital directors are willing to include you in their processes? Show them the money. Present scenarios that can be created by inaccurate coding products or code selection. Educate them on compliance issues affected by the proposed EMR product. References to possible federal fines and prison terms probably won’t be necessary if you get involved early enough in the project.

The coding profession shouldn’t fear change—we see code and process changes in our world annually, quarterly, and even daily in some cases. EMRs will most certainly affect how we do business, but diligence and awareness will maximize their benefit while keeping the negative aspects manageable. While our daily tasks will be modified by the digital document, the importance of the coder’s role remains as critical to the revenue cycle and to financial compliance as it has ever been.

— Judy Sturgeon, CCS, is the hospital coding senior manager at The University of Texas Medical Branch in Galveston and a contributing editor at For The Record. While her initial education was in medical technology, she has been in hospital coding and appeal management for the past 18 years.