Is Your Electronic Health Record Putting You at Risk for Documentation Audit?

A group of 3 busy orthopedists attended coding education each year and did their best to accurately code and document their services. As a risk-reduction strategy, the group engaged our firm to conduct an audit to determine whether they were documenting their services properly and to provide feedback about how they could improve. What we found was shocking to the surgeons, but all too common, as we review thousands of orthopedic visit notes every year: The same examination had been documented for all visits, with physicians stating in their notes that the examination was medically necessary. In addition, their documentation supported Current Procedural Terminology (CPT) code 99214 at every visit, with visit frequencies of 2 weeks to 4 months. The culprit of all this sameness? The practice’s electronic health record (EHR). “Practices with EHRs often have a large volume of visit notes that look almost identical for a patient who is seen for multiple visits,” explains Mary LeGrand, RN, MA, CCS-P, CPC, KarenZupko & Associates consultant and coding educator. “And that is putting physicians at higher risk of being audited or of not passing an audit.” According to LeGrand, this is because physicians are using the practice’s EHR to “pull forward” the patient’s previous visit note for the current visit, but failing to customize it for the current visit. The unintended consequence of this workflow efficiency is twofold: