False and Nonsensical Medical Records Reportedly Not Unusual

Poorly designed EHRs likely the culprit for the proliferation of false medical records.

Last week Talk Ten Tuesdays listener “Robert” discussed during the weekly Internet broadcast the fact that a physical examination documented in his medical record for a recent hospital visit was false, indicating that the physician never performed an exam.

Sadly, this is not a startling revelation or a unique occurrence.

Coders and auditors see false or nonsense documentation every single day. The difference in Robert’s story is that he is knowledgeable in coding and billing and had the expertise to evaluate the documentation. Most patients never see their medical record, and thus it is highly likely that innumerable cases of false documentation go undetected. More importantly, unless there is a noticeable error or other warning flag, coders and auditors may have no way to see below the tip of the iceberg.

This proliferation of false documentation is largely attributable to poorly designed electronic health records and similar templated documentation systems. The need for providers to document extensive notes to incorporate all the “quality” information and other payment methodology requirements has resulted in what is not-very-fondly referred to as “note bloat.” When we add in the Centers for Medicare & Medicaid Services (CMS) and CPT® Evaluation and Management (E/M) service documentation requirements, there is a lot of required information that may or may not be relevant to support a specific level of service.

The fact is that documentation takes an ever-increasing amount of time physicians often do not have. This results in attempts to streamline the process, and those solutions have the potential to create the exact opposite of the desired outcome. A very popular solution is the one-click methodology that creates a standard, pre-filled document. The thought is that the provider will edit and correct that standard to accurately reflect actual patient encounters. Unfortunately, but not surprisingly, that often does not happen.

As a result, we see patients suddenly re-growing limbs or anatomical parts they don’t have, a “normal” exam of a noticeable injury, no exam of the chief complaint, etc. In some cases, faulty editing makes a bad situation worse. For example, I just read a medical record for which the patient’s head exam included bowel tones. In many cases, the physical exam is in direct contradiction with the rest of the encounter documentation. Those are the obvious errors that are easily identified.

In Robert’s case, without a patient complaint, it is probable that the false documentation would not have been identified. However, at least Robert was really there that day. Cases of complete notes being produced when no patient visit occurred are also not uncommon. The practice of pre-populating the scheduled patient visits to edit later has also gained traction. If due diligence is not vigorously exercised, those completely false notes are billed.

A reasonable recommendation for Robert’s case was to contact the provider and/or compliance officer. Sadly, we have seen cases in which even that is ignored, and no corrections to the false records were made. In some cases, even the payer fraud units failed to respond, choosing to believe the medical record over the patient.

We know that the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) and CMS have been focused on these issues for quite some time. Interestingly, CMS in the proposed physician fee schedule requested input on revamping E/M documentation requirements, including the possibility of eliminating them.

The fact is that false documentation has the potential to cause great patient harm. More is not necessarily better. Documentation really should be customized, accurate, and useful for clinical care.

Until the focus is on what really matters, we have a huge problem requiring a solution.

Program Note: For more information on this subject listen to Holly Louie today on Talk Ten Tuesdays at 10 a.m. ET.

Print Friendly, PDF & Email
Facebook
Twitter
LinkedIn
Email
Print

Holly Louie, RN, BSN, CHBME

Holly Louie, a member of the ICD10monitor editorial board, is a former compliance officer and past president of the Healthcare Business and Management Association. Louie has been a guest cohost on Talk Ten Tuesdays with Chuck Buck.

Related Stories

Take Comfort in Her Advice

Take Comfort in Her Advice

When Angela Comfort adjusts her headset and microphone as she prepares to cohost Talk Ten Tuesdays this morning, one might forgive her as she momentarily

Print Friendly, PDF & Email
Read More

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

Revolutionize Case Management and Revenue Cycle Team Collaboration to Improve Patient and Financial Outcomes

Revolutionize Case Management and Revenue Cycle Team Collaboration to Improve Patient and Financial Outcomes

Unlock the keys to bridging the clinical-finance disconnect by transforming your approach to revenue cycle collaboration for superior patient care and financial prosperity!

Join Dr. Ronald Hirsch as he delves into the pivotal connection between case management, utilization review, and hospital revenue cycles, unveiling strategies to enhance communication and align goals effectively. Discover how to overcome hidden challenges hindering seamless collaboration and gain insights imperative for success

Print Friendly, PDF & Email
December 7, 2023
Mastering the Two-Midnight Rule: Keys to Navigating Short-Stay Admissions with Confidence

Mastering the Two-Midnight Rule: Keys to Navigating Short-Stay Admissions with Confidence

The CMS Two-Midnight Rule and short-stay audits are here to stay, impacting inpatient and outpatient admissions, ASC procedures, and Medicare Parts C & D. New for 2024, the Two-Midnight Rule applies to Medicare Advantage patients, requiring differentiation between Medicare plans affecting Case Managers, Utilization Review, and operational processes and knowledge of a vital distinction between these patients that influences post-discharge medical reviews and compliance risk. Join Michael G. Calahan for a comprehensive webcast covering federal laws for all admission processes. Gain the knowledge needed to navigate audits effectively and optimize patient access points, personnel, and compliance strategies. Learn Two-Midnight Rule essentials, Medicare Advantage implications, and compliance best practices. Discover operational insights for short-stay admissions, outpatient observation, and the ever-changing Inpatient-Only Listing.

Print Friendly, PDF & Email
September 19, 2023
Unlocking Clinical Documentation Excellence: Empowering CDISs & Coders

Unlocking Clinical Documentation Excellence: How to Engage the Provider

Uncover effective techniques to foster provider understanding of CDI, empower CDISs and coders to customize their queries for enhanced effectiveness, and learn to engage adult learners, leveraging their experiences for superior learning outcomes. Elevate your CDI expertise, leading to fewer coding errors, reduced claim denials, and minimized audit issues.

Print Friendly, PDF & Email
December 14, 2023
Coding for Spinal Procedures: A 2-Part Webcast Series

Coding for Spinal Procedures: A 2-Part Webcast Series

This exclusive ICD10monitor webcast series will help you acquire the critical knowledge you need to completely and accurately assign ICD-10-PCS and CPT® codes for spinal fusion and other common spinal procedures.

Print Friendly, PDF & Email
October 26, 2023
Inpatient Spinal Fusions: Mastering Anatomy, Coding and Documentation

Inpatient Spinal Fusions: Mastering Anatomy, Coding and Documentation

During this exclusive ICD10monitor webcast, inpatient coders will gain a profound understanding of prevalent spinal procedures. They’ll delve into the intricate anatomy, grasp the purpose and method behind these procedures, uncover essential elements within physician documentation, and receive expert guidance, step by step, on constructing accurate ICD-10-PCS codes. It’s the key to enhancing their expertise and ensuring coding precision.

Print Friendly, PDF & Email
October 26, 2023

Trending News