ICD-10-CM And EHR: What You Should Know

With the impending deadline for conversion to ICD-10-CM and the increased emphasis on electronic health records (EHR), this author offers historical perspective and how this combination may affect documentation and reimbursement in the near future.

I have been in clinical practice for 36 years. I have seen outrageous changes within the course of my career, now admittedly in its sunset, but I have observed and participated in/adapted to all these changes, and might be in a position to offer some perspective as the reforms of ICD-10-CM loom.

When I started in practice, no payers ever asked for copies of my medical records. In addition, I could submit my “superbill” via United States mail to a single local entity (our local Blue Shield payer), which would distribute it to all local and national payers. Then I got paid. The essence was: you submit your hard-copy superbill claim to one place, you get paid and no one asked to review the records.
When I started in practice, the state of California had the “audacity” to publish something called a “relative value study,” calculating relative comparative “units of value” among all available (not as yet called CPT) codes. Some considered the publication and distribution of this reference as price-fixing and it was illegal in many states. I am certain I still have my copy buried within the dusty stored boxes of my practice history.

At that time, I would receive a printed eight- to 10-page publication from my Medicare payer, indicating all the current updates, advisories and informational notices but such publications came quarterly.
Those days are long gone and we will never see them again.

There is a flood of incoming information and the demand/requirement for outgoing information is exploding. Payers are progressively expecting (and demanding) increasingly specific and precise diagnosis coding, typically paired with highly audited medical documentation.

In more recent years, there has been a huge impetus to encourage all healthcare providers to move toward an electronic medical/health record (EMR/EHR) system. In fact, next year, those who have not demonstrated successful and ongoing use of a qualifying EHR system can expect the Centers for Medicare and Medicaid Services (CMS) to penalize them. In addition, CMS is pushing for rapid implementation of an entirely new and more robust diagnosis coding system, ICD-10-CM. Although implementation has been delayed one or more times, CMS now adamantly states it will permit no additional delays, and all providers of healthcare services in the U.S. must use ICD-10-CM as of October 1, 2015.

I would first like to discuss some of the opportunities and challenges of use of EHR. We will then discuss the opportunities and challenges of implementing ICD-10-CM, and how they interface.

A Closer Look At The Evolution Of EHR

When I first started in medical practice in the 1970s, I inherited the vacated office of a general physician and surgeon. With the office, I inherited his patient records, which were on 3 x 5 cards. A representative example would have a single date of service, the single word “cholecystectomy,” the fee (admittedly in cash) and a check mark to indicate that the fee had been paid. There were no other records, whether medical or financial. Medicine was a cash business. You could maintain any type of medical record that you wanted as you were the only one who would ever read it.

Since the introduction of Medicare, there has been a growing presence of federal and private health insurance payers. As part of their fiduciary responsibility, payers want to ensure they only reimburse for covered medically necessary services. In this capacity, each individual payer can define what types of services it feels are medically necessary, what is sufficient medical documentation and what specific diagnosis codes or code combinations doctors should utilize in order to meet the threshold of medical necessity. Additionally, the payer reserves the right to independently review and audit your medical documentation and coding to ensure it meets its threshold requirements. Payers accomplish this by reviewing submitted diagnosis coding based upon coverage criteria, which may be published (as with Medicare) or private and proprietary (as with most private payers). To this end, they increasingly wish to review the provider’s medical records.  

Initially, virtually all plans had “open panels,” meaning that “any willing provider” could provide services to that plan’s patients and get reimbursement accordingly. Increasingly, so as to control cost and quality, many plans limit the number of physicians of particular specialties within their panels, essentially becoming “any willing category of provider” and no longer “any willing provider.” As part of their contract with each payer, the providers agree to abide by the payers’ rules of coverage and fee schedule. Providers also agree to openly, willingly and fully provide copies of their records.  

This means more and more entities are looking at your medical records. Initially, it was largely limited to health insurance plans but increasingly, the federal government is promoting total transparency of medical records (between insurance plans and between providers), whereby any entity can easily and readily access and review all other providers’ medical records regarding individual patients. That is a fundamental goal and element of “Meaningful Use.” As of this time, there are very few EHR systems that effectively provide that transparency across platforms.

As more and more entities have a very real interest in reviewing the quality and content of your medical records (and thereby your medical care), these entities are also demanding more in quality and content in those records.

There is no question that EHR is going to be the future of all clinical documentation. It is here to stay. However, particularly with a newly implemented EHR system, it takes a tremendous amount of time to implement and maintain such records. Accordingly, physicians are working longer hours and/or seeing fewer patients. When these systems are designed and used appropriately, providers can save a great deal of time by utilizing some of the features that computers do best, such as using templates, macros, copying and pasting, or pulling forward documentation from prior visits.

One argument in favor of the use of templates is that if physicians craft them correctly, templates can guide providers through appropriate considerations in the management of complex problems. In essence, as the provider works through the template, it reminds him or her of what types of questions to ask, evaluations to perform, etc., and that can result in better quality care.

In the words of a forum on EHR: “It’s a thing of beauty to see a full template pulled into a patient’s chart with a single click. A full patient physical documented with a single click sounds like it should save the doctors a lot of time and make them more efficient.”¹

In its most simplistic form, there are several elements to consider in any patient encounter:
• The nature and content of the medical record
• The CPT coding for that “encounter”
• The diagnosis codes submitted in support of that encounter

The fundamental element that trumps all other components is “medical necessity.” One definition of medical necessity is balancing the intensity of the services provided with the need. If the patient is otherwise healthy and presents with a simple, straightforward and self-limited problem, it is not “medically necessary” to perform a huge, comprehensive, multisystem workup and evaluation, and payers do not want to pay for it.

Understanding The Pitfalls Of Auto-Populating And Cloning EHR
The seeming default of auto-populating, copying and pasting, and “cloning” EHR documentation is perhaps all too tempting. However, in the process, providers can carry forward portions of the history and examination that they did not really perform. In addition, such documentation increasingly starts to become the same for each visit and for every patient with a resultant lack of specific individual patient information.

Medicare and Medicaid consider this a form of abuse. Tews quotes the Medicare Part B Update in the third quarter of 2006 (volume 4, number 3) as stating: “Documentation is considered cloned when each entry in the medical record for a beneficiary is worded exactly like or similar to the previous entries. Cloning also occurs when medical documentation is exactly the same from beneficiary to beneficiary. It would not be expected that every patient had the exact same problem, symptoms, and required the exact same treatment.”²

In addition, Tews notes that “Electronic health records (EHRs) are supposed to save providers time and improve the quality and legibility of their documentation. Another hoped for advantage of EHRs is better patient care. EHRs are not intended to increase the quantity of documentation solely to support billing higher levels evaluation and management (E/M) services.”

“A general rule is that if you did not document it, you did not do it,” states Mitchell Hilsen, DPM.³ “But the corollary is also true that if you do document it, you had better have done it. If you didn’t do it, don’t document it.”

James Christina, DPM, suggests, “Relying heavily on templates or cut-and-paste features of patient notes may lead to issues such as cloned notes. Make sure you customize the note for each individual patient visit, even if there are a lot of similarities from visit to visit.”⁴  

A fundamental principle of any EHR system, and one of its popular features, permits physicians to bring past records forward into today’s record (essentially copy and paste), “auto-populate” fields, and utilize templates and macros. I read a lot of EMRs/EHRs. Most of the records are 10 to 12 pages long, full of repeated past family and social history, detailed review of systems, exhaustive workups, and a lot of extraneous detail so it is hard to find the really relevant and pertinent content. In some of the records I have reviewed, even after a careful review, I still cannot find any relevant or pertinent content. It appears that healthcare providers are so busy trying to get the job done (complete the patient’s medical record and move on to the next patient) that they don’t have the time, opportunity or willingness to leap out of the template and copy mode, and create concise, comprehensible, coherent and meaningful content regarding the individual patient’s chief complaint.

A few years ago, I reviewed 265 pages of electronic health records out of a large multispecialty clinic, specifically to evaluate a claim for permanent disability for a postal worker on the basis of plantar fasciitis. Upon a careful review of all 265 pages, I literally found one sentence that even mentioned heel or arch pain. If that is truly the basis for this patient’s claim for permanent disability, these are not good records. They may well be robust but they are not good medical records.

Payers are already concerned that providers, whether out of laziness, taking the easy way out or perhaps in a volitional attempt to support higher levels of reimbursement due to the content of their EHRs, will code for higher levels of E/M services and greater reimbursement. Payers (and reviewers for payers) have been utilizing “plagiarism software” to identify blocks of text copied from other medical records, and the Office of the Inspector General (OIG) has begun comparing multiple patients and multiple visits to detect “inappropriate documentation” as a fundamental element of its 2014 OIG Work Plan.⁵

In addition, the patient can complete or the staff can document certain portions of the medical record, but the physician must do the history and physical. Electronic health records track who actually inputs content into the medical record. Payers are increasingly analyzing the submitted EHR to determine who actually performed elements of the medical record.  

Where EHR And ICD-10 May Collide

The ICD-10-CM is far more detailed and robust than any diagnosis coding system ever used anywhere, especially in the U.S. A fundamental principle in ICD-10-CM coding is to code the highest level of detail possible and ICD-10 provides for extremely high levels of detail. The CMS calls that level of detail “granularity.” Yet another fundamental principle in ICD-10-CM coding is that you can only code to the level of detail and content within your medical record, and that is where the EHR and ICD-10-CM collide/interface.

A well-crafted EHR can potentially provide for significant levels of detail and granularity. However, the constraints of time, energy and attention on the part of physicians might “encourage” them to not develop the record to that level of granularity, making the record more generic. (Note that I did not use the word “laziness.”) Accordingly, many EHR-generated medical records are too non-specific and generic to meet the demanding “granular” criteria of ICD-10-CM. Then the following scenarios could develop:

• One must necessarily submit the claim with non-specific and unspecified codes. Payers expect and will accept non-specific codes initially, but they expect the diagnosis coding to be much more specific over time.
• The EHR “suggests” diagnosis coding based upon the content of the record. This is a really bad idea.
• The CMS indicates that, if coders upon review of the submitted EHR documentation cannot come up with a specific code, CMS must “query the provider.” That means going back to the physician of record and asking him or her to amend the record with additional detail so as to meet the granularity requirements. I can envision that going over well.

The very nature of an EHR allows one to auto-populate fields so as to generate a complete and robust medical record. However, the nature and extent of that generated record might be grossly in excess of the medical necessity for the presentation, seemingly submitted in consideration for reimbursement of a higher level of E/M than what would otherwise be warranted (i.e., “medically necessary”). This is “upcoding.” Payers are very concerned about this and will be auditing accordingly.

“There are troubling indications that some providers are using this technology to game the system, possibly to obtain payment to which they are not entitled. False documentation of care is not just bad patient care; it’s illegal.²

“Some providers create a single comprehensive history, with complete review of systems, history and examination, and use it for all their patients. To the contrary, it is suggested that providers build one template for each level of medical decision-making: low, moderate and high complexity.”²  

In Conclusion

As we evolve in the electronic age of medical care, there are rapidly developing changes in diagnosis coding and medical documentation. When used and configured properly, a quality EHR system can certainly be of great benefit in documenting the medical history, examination and treatment fully in support of the higher requirements of the specificity/granularity required and inherent in the newly developed ICD-10-CM.

To the contrary, if physicians do not use these technologies intelligently and appropriately, there is a great risk of increased audit, rejection/recoupment of payments, etc.

Dr. Horsman is in private practice in Olympia, Wash.

References

1.    Lynn J. The coming physician EHR revolt. EMR & HIPAA- an open forum. Available at https://www.emrandhipaa.com/emr-and-hipaa/2013/02/05/the-coming-physician-ehr-revolt/ . Published Feb. 5, 2013. Accessed Nov. 14, 2014.
2.    Tews R. Set up templates so cloning is not questioned. Healthcare Business Monthly (AAPC). Available at https://news.aapc.com/index.php/2014/06/set-up-templates-so-cloning-is-not-questioned/ . Published June 1, 2014. Accessed Nov. 14, 2014.
3.    Personal communication with Mitchell Hilsen, DPM.
4.    Christina J. Mistakes made with electronic health records. APMA News, July/August 2014. Available at https://www.apma.org/WorkingForYou/content.cfm?ItemNumber=1987&navItemNumber=702 .
5.    Stearns M. Warning: import text properly- ensure clinical documentation integrity in your electronic medical records. Healthcare Business Monthly (AAPC). Available at https://news.aapc.com/index.php/2014/06/warning-import-text-properly/ . Published June 1, 2014. Accessed Nov. 14, 2014.

Additional Reference

6.    Risotti-Hinkle E. Watch out for misused EHR documentation shortcuts. Healthcare Business Monthly (AAPC). Available at https://news.aapc.com/index.php/2014/07/watch-out-for-misused-ehr-documentation-shortcuts/ . Published July 1, 2014. Accessed Nov. 14, 2014.