Smart tech: Understanding the role of EHRs and provider documentation in denials

The EHR is often set up to prompt the provider to capture certain documentation. Although this is usually done to help the provider capture complete information while saving time, overreliance on these features can ultimately have the opposite effect. Occasionally, the EHR setup includes autofilling fields assuming that the provider has assessed certain systems or conditions and may even permit copy-forward of prior documentation. Unfortunately, the autopopulation features of EHRs often incorporate canned documentation that may be more detailed than what is actually discussed between the patient and provider.

Payers review the diagnoses and compare to the examination performed. If an excessive exam is performed for a simple condition, it might raise the E/M level superficially. The higher E/M level will be considered unjustified and denied. CMS, Comprehensive Error Rate Testing, Recovery Audit Contractors, Office of Inspector General, and commercial payers perceive risk with E/M leveling and EHRs, so profiling of providers against others in the same specialty is conducted to identify variations.

Some common reasons for physician/provider denials include:

• Incorrectly coding a visit as a new patient when the patient is considered established. For a patient to be considered a new patient, the patient must not have received any professional services within the past three years from any provider of the same specialty within the practice and must meet the E/M elements of history, exam, and medical decision-making.
• Visit level does not meet medical necessity.
• Inadequate support for a consultation. Consultations require specific documentation. There must be a physician request for an opinion or advice, the request must state a reason to justify the need for a consultation, and the consultant must render an assessment of the patient and create a written report of their findings and recommendation.
• Lack of sufficient documentation to support time-based encounters.
• Maintenance therapy by chiropractors.

Keeping a pulse on trends in physician/provider denials allows the coding compliance auditor to proactively review cases to identify vulnerabilities existing within the physician practice. If these denials are occurring within the practice, then reactive auditing may be necessary to reduce denial occurrences for the practice.

The coding compliance auditor’s role is to periodically review the E/M levels being claimed for the organization’s employed providers.  When conducting these reviews, the auditor should assess whether all documented diagnoses have been coded and submitted on the claim. Doing so helps to demonstrate the complexity of the care process for the individual patient. Procedure codes should be assessed as well to ensure that current procedure codes are being used. Additionally, with the increased attention being given to transparency and public profiles by insurers and patients, there is an opportunity for the coding auditor to teach coders how to provide clinical documentation guidance to providers so that the providers can more accurately depict the complexity of an outpatient’s condition.

When scenarios surface like the ones described above, the auditor may need to work with information technology and the provider to reset the parameters of the EHR to avoid overbilling the service level and exposing the organization to external payer audits and denials. We should educate our providers to ensure the services rendered are based on the medical necessity of the visit and that services are properly documented and categorized as new, established, or consult. Ideally, the physician’s notes should tell the story about the patient’s condition and how it will be addressed.

Note: This article was excerpted from The Essential Guide to Coding Audits, by Rose T. Dunn, MBA, RHIA, CPA/CGMA, FACHE, FHFMA, CHPS, with contributions from William L. Malm, ND, RN, CRCR, CMAS.