Documentation and Compliance Risk: Top Areas to Watch

February 25, 2013 / By Donna Smith, RHIA

As the country moves to automated record-keeping in health care, there are certain areas that need to be scrutinized prior to assigning codes for billing. Compliant coding is of utmost importance, not only for healthcare providers, but also for government auditors. While new technologies are being introduced daily, the government has warned that it will not tolerate providers who try to “game the system.”

The top areas that must be evaluated by providers in determining how to use technology include:

Problem Lists – The use of technology has advanced the problem list as a method of documenting all health conditions for the patient. While this is an admirable goal, there are many flaws with the current problem lists, especially if the diagnosis itself is selected from a drop-down menu which also assigns a code. The first consideration of this documentation should be who is entering this information: is it a licensed provider? The second should be: who is responsible for updating the list as problems are resolved.

Consider this scenario:  a patient is prescribed antibiotics for a urinary tract infection in the outpatient clinic. The diagnosis of UTI is placed on the problem list. Several weeks later, the patient is admitted to the hospital for elective surgery. Although the UTI is resolved, it is still listed as an active diagnosis on the problem list which is pulled into the current inpatient record. This puts coding and CDI staff in a quandary trying to discern if this UTI currently exists. The risk here is that it could get coded into the patient record. Additional issues with problem lists involve inaccuracy of the diagnosis code based on the formatting of the drop-down list of diagnoses and the frustration of the physician trying to locate the precise diagnosis.

Copy/Paste – While this technology is used regularly and extensively in all types of settings, its use is inherent in EHRs. Organizations need to implement significant policies & procedures around use of this functionality and its use needs to be monitored. What the industry is seeing is that 1) incorrect information multiplies exponentially throughout the record as well as subsequent record and 2) it is difficult to discern what is new or different with the patient today as compared to previous days.

In addition to the manual process of copying one note and pasting into the next note, there are also EHRs that are set up to automatically populate certain parts of the record. In some cases, the information copied might be from a different admission or an outpatient visit. If the diagnoses that are listed in this documentation but not valid for the current inpatient stay are selected for the final billed record, inaccurate coding can result.

Compliant Queries – AHIMA and ACDIS have collaborated on a Practice Brief that details “Guidelines for Achieving a Compliant Query Practice.” While this is not a regulatory document, these organizations represent best practice for the industry. Leading queries, where the physician is asked outright if a diagnosis should be documented, are at the top of the areas addressed. The document lists appropriate situations that would seem to allow the generation of a query and some sample wording. A compliant query should include clinical documentation to support the request, be written as to not lead the practitioner to a specific diagnosis and ultimately to allow for integrity of health care data.

Computer-Assisted Coding – Technology is now available to streamline the capture of data by using a Natural Language Processor (NLP) to “read” through the record and identify codeable diagnoses and procedures. Computers can also be taught to follow some of the rules and regulations surrounding coding, thus eliminating those types of errors. However, there still needs to be a human element that validates the computer’s findings.

Hospitals should determine how they stand with use of the technology noted so that only complete, accurate, and compliant diagnoses and procedures will be reported.

Donna Smith is a Project Manager and Senior Consultant with the Consulting Services business of 3M Health Information Systems.