So, you purchased an electronic healthcare record (EHR) program.
Congratulations! Maybe you were one of the early adopters who were riding the incentive wave that allowed you to tap into that $44,000 per eligible provider. Maybe you jumped on the bandwagon a little later. Either way, you took the plunge, and you have the software. Now how’s it going?
Old habits die hard
If you’re like many if not most, those first few days and weeks with your new software were a far cry from what you had thought they would be. You were frustrated, confused, and befuddled. Perhaps you cursed the day you ever heard the name of your software company and wanted to toss it, along with your computer, out the window.
It’s not uncommon to feel a powerful desire to go back to the good old days of writing your notes by hand using a system that possibly only you understood.
But you persevered and became more comfortable with your EHR system. You became more adept at creating an electronic SOAP note. Maybe you created some macros to help this process along. It is also entirely possible that you discovered some shortcuts or cheats along the way.
Same as last time
Far too many users of high-end EHR programs mistakenly think that because their software is certified, that is all that’s needed with respect to compliance in documentation, coding, and billing. Spend a day in my office listening to phone calls from doctors who are being audited and you’ll see what an error that can be. If your software is to accomplish what it was designed to do for billing, coding, and documentation, it needs correct information to be entered into it.
A vivid case in point was a practice that was making aggressive use of “same-as-last-time” (SALT) procedures. Too much salt is not only bad for your health when you put it on food, but it can have similar negative effects when there is too much SALT in your documentation.
This group practice in question was like a growing number of practices in in the U.S. who are moving toward a multidisciplinary style of practice. They have chiropractors, a medical doctor, and physical therapists on staff. Care is coordinated and each healthcare provider sets their own independent treatment protocols. This certainly sounds good on paper.
This practice requested a periodic chart review as part of their annual compliance activities. We had been familiar with this practice when they were chiropractic-only, and this was the first time we were looking at their charts as a multidisciplinary practice.
When it came to their rehab notes, SALT ruled the day. There was SALT everywhere. You might think nothing of this as rehab is often done in phases and often not a lot changes from visit to visit.
However, a huge problem was uncovered: The practice’s medical doctor had documented on one visit that he was giving a patient the first of an anticipated three trigger-point injections. The note regarding this procedure was beautiful.
It described the preparation of the medicine to be injected, the lot numbers from the vials, the gauge of the needle, the muscles to be injected, and post-injection recommendations to the patient. The patient also received rehab services during this visit from the physical therapist. These notes also looked fine. So what was the problem?
Upon review of the next two dates of service, we found that they had SALTed their notes. In the process, the wonderful and complete description of the first trigger point in a series of three also appeared. Their software also generates billing automatically from the notes that are entered on each encounter. As such, this first injection was billed a total of three times, when no trigger point injections were performed on the second and third dates of service.
Worse yet, on a deeper dive into their records, we discovered they were also paid for these two additional injections that never happened—a major compliance goof!
Fortunately, this practice had a living compliance program in their office, not merely a manual siting on a shelf collecting dust. This error was documented, training was given to all staff, a refund provided to the insurance company, and there is now a dramatic decrease in the use of SALT in this practice. Crisis averted? One can hope.
Evolve with the times
Putting an EHR system in your office is a good thing to do. It is the sign of a practice that is modern and making efforts to keep up with the information age. It will allow your practice access to information and you can use it to communicate seamlessly with other healthcare institutions.
But if you use your software programs pretending that it is still the 1980s or 1990s, you will see those benefits evaporate. Worse yet, you could run the risk of having to make crippling refunds for services that were not adequately documented to prove medical necessity.
Those of us old enough to remember the early days of computers in practices will recall the acronym GIGO: “garbage in, garbage out.” This concept is alive and well today and lives in your computer. Put garbage documentation in, you can expect garbage out in the form of poor reimbursement, refunds to carriers, and a profile with carriers that is less than stellar.
Kathy Mills Chang is a certified medical compliance specialist (MCS-P), a certified chiropractic professional coder (CCPC), and certified clinical chiropractic assistant (CCCA). Since 1983, she has provided chiropractors with reimbursement and compliance training, advice, and tools to increase revenue and reduce risk. She leads a team of 20 at KMC University and is considered one of the profession’s foremost experts on Medicare, documentation and compliance. She or any of her team members can be reached at 855-832-6562 or firstname.lastname@example.org.