Regulatory Update: Physician Practice Management – E/M Documentation

March 4th, 2013 / By Barbara Aubry, RN

Last month, I blogged my thoughts on the top ten compliance problem areas for physicians; this month, I am sharing a few thoughts on how practice managers can help with these problem areas.  Yes, I know physicians may not be fond of being “managed,” but there are some things you can do to help yours—even  the reluctant ones.


Billions have been invested in EHRs/EMRs in the hope they will improve healthcare and reduce costs. Yes, I know the jury is still out on that, but documentation is super-important now more than ever before. With liability still squarely on the physician— and yes, I agree it’s not fair—it remains very important for your physicians to document really, really well. They know all the reasons why they need to do this from a liability standpoint, so I’m not going to repeat them here, but I suggest you remind them anyway.

Cloning and practice liability

Personally, I wish EHR/EMR software had been built so it would be impossible for users to copy and paste data (cloning). I wonder if clinicians were involved during system design and development decisions. Or maybe it just didn’t occur to the designers how the function would be misused. Regardless, remind your physicians that cloning causes problems for coders and (more importantly to them) that it also causes potential legal liability issues should there be need of review of their care.  Can you imagine what a lawyer would say about a cloned medical record?

E/M fraud

Finally, if the physician clones the review of systems (ROS), past medical and family history (PFSH) and examinations and their records are audited, the level of complexity and medical decision making for purposes of assigning E/M codes will be in question.  The Office of the Inspector General (OIG) released a study in May of 2012 titled, “Coding Trends of Medicare Evaluation and Management Services’’.” In it, they say between 2001 and 2010, Medicare payments for E/M services increased by 48 percent to $33.5 billion. They state, “E/M services have been vulnerable to fraud and abuse. In 2009, two healthcare entities paid over $10 million to settle allegations that they fraudulently billed Medicare for E/M services.”  CMS agreed with the OIG suggestion of further educating doctors, having the Medicare Administrative Contractors MACs do record audits and partially agreed with the suggestion that the OIG specifically review practices that have a history of billing higher than usual E/M  codes.  I don’t suggest that your physicians under code their E/M services, but I certainly hope they stop cloning. Document what is necessary to accurately reflect the care provided. The current climate is challenging enough for physicians – this is one area where they can take control and make their lives a bit easier .

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Barbara Aubry is a Regulatory Analyst with 3M Health Information Systems.