Documentation: Understanding EMR Systems

Moira Hayes, MHA, RRT, CHT

Compliance in the US generally means adherence to laws and regulations. Corporate scandals and breakdowns such as the Enron case in 2001 have highlighted the need for stronger compliance regulations for publicly listed companies. In the medical world, focus is on maintaining regulatory compliance in all activities of documentation and coding for billing professional services. The importance of documentation has been emphasized throughout this issue of TWC. With regulatory organizations closely monitoring activities, patient quality of care at stake, and the financial success of a wound center dependent on the quality of documentation, a compliance process is an absolute necessity. How will wound centers ensure what ends up in the chart accurately reflects the care that was provided to the patient, as well as the services that were billed?

Auditing Options Under An EMR System

Although physician and facility billing are controlled by separate governmental requirements, there are two overarching principles which apply to documentation compliance:

1) Billed level of service must correlate with the level of service documented in the chart. This is applicable for both the physician and the facility.
2) In some circumstances (ie, surgical excisional debridement), the level of service billed by the physician and the facility must correlate with each other.
Many healthcare organizations have been scrutinizing the documentation and revenue cycle of their outpatient wound care programs. Some organizations have no audit process at all, while others may audit 100% of charts, involving many hours of resources. However, most audit programs fall somewhere in between. Not only must a facility determine the method of audit, but the sample size. Some facilities may choose to perform a random audit of a specific percentage of charts (ie, one chart in 10). Alternatively, all charts might be audited over a specific time frame (eg, 1 month).

Typically, one of the following three methods is used to determine the billed level of service for either the physician or the facility:

1) Abstraction of the paper chart by a trained expert.
2) Allowing the provider to estimate their level of service and select it on the charge master.
3) Using an electronic medical record (EMR) to directly calculate the billed level of service based on documentation.

Abstraction of the chart by a professional coder continues to be the gold standard, particularly in relation to physician level of service. Depending on the training and skill of the coder, this is more than likely the most accurate method of ensuring correct correlation between clinical documentation and billed level of service. Abstraction is the most expensive yet least efficient billing method. Professional coders are also the gold standard for the abstraction of the diagnostic and procedural levels of service provided in a facility. However, there is an almost crippling shortage of qualified medical coders which threatens the revenue cycles of many institutions, as discussed by Kathy M. Johnson in the February issue of the Revenue Cycle Strategist.1 Abstraction of charts might be a reasonable method for performing a focused audit of billed charges, but it is not a practical method to determine the billed level of service on a day-to-day basis for billing purposes.

In day-to-day practice, the most common method for determining billed level of service is simply to have the provider estimate the work they have provided, based on their personal assessment of the subsequent clinical documentation. The problems associated with this option in the wound center setting have been described previously. Dr. Fife and colleagues demonstrated that allowing facility staff to estimate the level of service they provided (using time as a metric) consistently resulted in an over-estimation of actual services when compared with specific measures of staff work.2 Physicians may not be any better than nursing staff when it comes to using their own documentation guidelines. A recent study compared the coding accuracy of 600 family practice doctors with professional coders.3 Family physicians agreed with the experts that only 17% of the time for new patient visits, the predominant error being over-coding by physicians. Thus, data suggest that when either physicians or nursing staff estimate their level of service after seeing a new patient, they will over code. The over-coding is probably due to the difference between the work one perceives one has provided, and the necessary documentation to justify this work. Even though a higher level of care might have actually been provided, if the documentation does not support the level of service, which was billed, it is still considered over-coding.


1. Johnson, KM. The massive medical coder shortage. Revenue Cycle Strategist. 2008;5(2):1–3. 2. Fife CE, Walker D, Farrow W, Otto G. Wound center facility billing: A retrospective analysis of time, wound size, and acuity scoring for determining facility level of service: Ostomy Wound Manage. 2007;53(1):34–44. 3. King MS, Sharp L, Lipsky MS. Accuracy of CPT evaluation and management coding by family physicians. J Am Board Fam Pract. 2001;14(3):184–192. 4. Silfen E., Documentation and coding of ED patient encounters: an evaluation of the accuracy of an electronic medical record. Am J Emerg Med, 2006;24(6):664–678

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says: December 4.2010 at 18:55 pm

I enjoyed learning about the intricate and detailed auditing process in relation to the EMR Systems.

With regard to Medicare billing, since the inception of the Medicare Modernization Act of 2003, it has allowed the increase of private health carriers who can now offer supplemental Medicare benefits under the Medicare Advantage Plans Program.

It would be interesting to know how many of these carriers participate, or have participated in the "Random or One- Chart" auditing strategy to accomplish and derive the most accurate results?


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