Does the Screen Reflect the Printed Page? Assessing Documentation Mismatches

Although electronic health records (EHR) may be easier to read than traditional pen and paper charts, they may not automatically result in a clearly painted picture of the patient’s condition and the clinical care provided. Most wound/ulcer management physicians and other qualified health care professionals (QHPs) learn to write detailed notes about each patient encounter, create and document a treatment plan, and document progress in meeting the treatment plan’s goals.

Foundational Facts to Consider

Wound/ulcer management professionals and providers are experiencing an increasing number of audits from all payers. If they fail the pre-payment or post-payment audits due to poor documentation, they typically face claim denials and/or large repayments.  

Facts to Consider:

•     EHR documentation should fully reflect execution of care driven by clinical practice guidelines.  

•    How physicians/QHPs learned to document throughout their medical education should not change regardless of the modality of documentation (electronic versus pen).

•    Documentation should always include the components required by Medicare’s National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), and Local Coverage Articles (LCAs).

•    Documentation should provide:  

1) a clear picture of the patient’s problem, results of all diagnostics, the treatment plan, procedures performed, drugs and devices ordered, and next steps;  

2) clear guidance for the entire medical team, including the next site of care; and  

3) all of the information in a readable format for any auditor/lawyer who requests a particular medical record.

Taking A Closer Look at Your Own Documentation

It is essential to analyze and refine one’s documentation before an external audit occurs.  

The best place to learn details specific to your practice are from the LCDs and LCAs available from your local Medicare Administrative Contractor (MAC). Some examples, however, of possible gaps in documentation that can contribute to repayment requests and failed audits include¹:  

• The assessment says the wound/ulcer is 100% granulated and the physician then performs a subcutaneous debridement.
• A patient has five wounds/ulcers, but the documentation does not track the care of each one individually.
• Orders for next visits and/or procedures are missing.
• Time is not reported for services and procedures where required.

There are two key process improvement action steps that physicians and other qualified healthcare professionals may take to help avoid such situations.  

1.    Print and read one’s documentation of patient encounters before external audits occur. Because many wound/ulcer management physicians/QHPs focus on completing each EHR screen so they can close and sign the encounter, they may not realize their responses on different screens could provide a contradictory picture of that encounter. They also assume the different EHR screens include all the information required by NCDs, LCDs, and LCAs, which auditors use when they review documentation.

Instead, they should compare the information on the EHR screens to how it reads in the printed medical record. Additionally, they should verify that the documentation aligns with the requirements of pertinent NCDs, LCDs, and LCAs.¹

2.    Direct or directly participate in the collection of medical record documentation and read it before sending to an auditor. Physicians and other QHPs do not consider that the billing and coding team does not have all the medical knowledge about the patient encounter that is the subject of the audit. Therefore, they allow someone in the billing/coding team to prepare and send the documentation packet to the auditor.  Without they professional’s oversight, the billing/coding team might not include all available documentation or might not assemble it in an order that paints a clear picture of the patient’s encounter.

When physicians/QHPs review documentation packets that will be sent to auditors, they should verify:

• Are any required documentation components missing?
• Does the documented diagnosis justify the medical necessity for the work performed?
• Does the printed medical record include an updated treatment plan, physician/QHP orders for the work performed, a description of procedures performed, and a compliant physician/QHP signature?
• Is the order of the assembled documentation components logical and does the packet fully reflect the patient’s encounter?  

It is important to note that an EHR vendor is only responsible to provide the digital documentation tool. It is up to the physician/QHP to ensure correct documentation. If an EHR software causes liability issues, the physician/QHP or organization should work with the EHR vendor to revise the software or to create a work-around to protect her/his/their practice. Vendors should promptly make requested refinements and should provide advanced inservices or other educational opportunities to enlighten physicians/QHPs as to how each of the documentation screens knit together to create the final medical record. Practicing with any revisions that are made to the software to assure concordance with the printed medical record is also vital. Auditors cannot read information not documented or not appearing in the printed report.  

Conclusion

Physicians/QHPs should take responsibility for their own documentation and for the way it prints out as a medical record encounter. In addition, physicians/QHPs should direct or directly participate in the collection/assembly of the medical record components when auditors request documentation for particular patient encounters.   

This article is adapted and originally appeared on Today’s Wound Clinic.