The physician should have the ability to make changes and customize each patient’s documentation in an electronic medical record.
Courtesy of Hemera\Thinkstock


Published 7/1/2012
Peter Pollack

EMR Compliance Depends on Good Practices

Timely, complete, accurate records are essential

Authorship and accuracy are two keys to being compliant with electronic medical record (EMR) requirements according to Ranjan Sachdev, MD, MBA, CHC, an orthopaedic surgeon in private practice in Bethlehem, Pa., who is certified in Health Care Compliance. Speaking at the Practice Management Symposium for Practicing Orthopaedic Surgeons during the 2012 AAOS Annual Meeting, Dr. Sachdev outlined areas of compliance risk when using EMRs.

The key to avoiding problems, he explained, is maintaining timely, accurate, and complete records. Records that fall short of those goals are more likely to be subject to audits or payment denials.

Who gets the HPI?
Because EMRs track the authorship of each entry, Dr. Sachdev explained that it is important for the provider who obtains the history of the present illness (HPI) to be qualified and to properly enter the information in the patient’s record.

“U.S. Centers for Medicare & Medicaid Services (CMS) guidelines, as interpreted by Medicare Administrative Contractor (MAC) administrators, insist that the provider obtain the HPI. A medical assistant can obtain past medical history, personal history, social history, and review of systems, but the provider must obtain the HPI,” he noted.

Dr. Sachdev pointed out that allowing a physician’s assistant (PA) to perform the physical examination, obtain the HPI, and enter the notes into the EMR for new patients may be problematic unless these services are billed under the PA’s provider number.

“In some practices, the PA does all the work and documentation and then the physician comes in and fine tunes it,” he said, “but CMS does not allow that. CMS does not allow split visits or incident to billing for new patients, and the billing physician has to perform the greater part of the exam, make the decisions, and review or obtain the HPI. Otherwise, the work has to be billed under the PA, if the state scope of practice law allows it.”

According to Dr. Sachdev, use of a medical scribe is allowed, provided the scribe enters the physician’s quotes exactly.

“That’s the definition of a scribe—word for word,” he said. “If your scribe is taking the HPI and entering it into the EMR, the allowable CPT code for the visit level drops down to a Level 1 or 2. The best approach to record-keeping is to make a note that explains how the HPI was taken and entered, or use a separate login that clearly says that the orthopaedic surgeon did it.”

Cloned or exploding documentation
Another set of pitfalls involves the use of cloned documentation and exploding records.

“First of all,” Dr. Sachdev said, “you can’t just cut and paste somebody else’s note. That’s frank plagiarism.

“Second, you also cannot copy your own note, word-for-word, for different encounters. That is called cloned documentation. We all understand that little may distinguish one patient encounter from another and some essential facts can be carried forward. But if the notes are exactly the same every time a patient comes in, you won’t be able to convince an auditor that you’ve been doing your job properly.

“When you consistently copy notes, your ability to claim that a course of action was medically necessary goes out the window. You also risk incorporating improper or inappropriate documentation into a note.”

Exploding documentation occurs when an EMR macro is set up so the physician can check an entry box and expand the macro into an entire note.

“It’s perfectly legal to use templates and macros,” said Dr. Sachdev, “but it is not okay to check a box and have all the macros generate a series of entries without your having the ability to pick and choose. The physician needs to be in control of the documentation.”

Accuracy is important
Dr. Sachdev pointed out that another problem with exploding documentation is an increased likelihood of inappropriate information being added to a patient’s record.

“When you are examining a healthy young person for trigger finger, it probably makes no sense to conduct a lower extremity examination,” he said. “Yet exploding documentation could add just such an entry, and you’ll end up billing for a Level 4 office visit.

“At a recent compliance meeting, an attorney gave an example of inappropriate documentation seen in an EMR-generated note. The note read ‘Testes are normal in shape and size, with no evidence of enlarged prostate on rectal exam.’ Yet the patient was a 30-year-old female. It’s very hard to argue that you conducted that examination. And if the system added that kind of information without the physician’s actually recording it, what else did it add?”

Other areas of concern, according to Dr. Sachdev, are potential overpayments because of miscommunication.

“You tell your radiography technician to do a complete view of the knee,” he explained. “That’s four views. She assumes it’s a standing AP lateral and does three views. The billing goes out saying four views were done, and now there’s an overpayment issue.”

The value of a dry run
To minimize EMR compliance issues, Dr. Sachdev recommended reviewing templates and deleting procedures that are never performed.

“Orthopaedic surgeons don’t normally look into pupils or at rectums,” he said. “So those items in a visit template are not needed. Simplify your system.”

In addition, he proposed performing a “dry run” of the EMR system before using it with actual patients.

“Take some test patients and run them through the system,” he suggested. “Do an audit to make sure that the notes are what they should be and that no irrelevant facts show up. Educate your partners on the evaluation and management coding rules, because false claims liabilities and overpayment are probably the two biggest issues you’ll face.”

Other issues center on privacy and security policies.

“You need to look at the possibility of a security breach and document how you intend to handle it,” said Dr. Sachdev.

“As you transition to EMRs, remember that you need to be able to document the medical necessity of whatever you bill, especially in cases of self-referral. You should be able to identify who did what work. Avoid including too much information, and personalize the documentation so it is specific to the patient,” he concluded.

Peter Pollack is a staff writer for AAOS Now. He can be reached at

Additional Resources