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Risk Topics: The Pitfalls of EHR-Practice Management Software Connectivity

By: Reed D. Gelzer, MD, MPH, CHCC

A major source of risk in combined EHR/Practice Management (PM) systems is how they interact with tentative actions. For example, some systems offer the choice to the User to send the charge information to the billing system before the documentation is completed and signed. Think about that for a minute... A common practice in the paper world has been to hand the patient the paper superbill so they can carry it to the discharge desk., then the provider will finish the documentation as an unrelated task.  Since the documentation is also to demonstrate the medical necessity of the service, though, documentation should be complete at the time of billing for the service.  Having this “disconnect” between the documentation and the billing also risks that the documentation may not be completed in a timely way.  Previously the detection of post-dated documentation has been nearly impossible to detect and prevent and so it’s a habit that may be difficult to change in the EHR environment, which will show when the documentation actually occurred. 

However, now that you have an all-computerized set of processes in place, an auditor can come to your office and pull, say, all the Medicare charge events from your PM system (or has your EOB from a few months back) and just goes thru your EHR and check the date and time stamps to see when you actually completed the documentation.  In the process the auditor finds a pattern of behavior of completing the documentation after, perhaps even a day or two after charges were submitted.  Perhaps the auditor even finds a few encounters that never got completed and signed at all... See the problem?

So, review the principle. Medicare (and payers) pay for services that are medically necessary. The documentation is the support of medical necessity. If the documentation to support medical necessity is done AFTER the bill is rendered, that is problematic. If the time lapse is hours, the same day, this may not be a problem.  Your office should have a written policy to state what your standard is and how you established it, and then all should stick to it.  If your system can show that you routinely complete documentation days later than the bill was rendered, and you have no policy, then what you’re doing is in fact your policy and it does not look good.

This also suggests a shopping tip when evaluating EHRs.  Some systems have prompts for outstanding, unsigned encounters.  Some can be set up to administratively block charges submission until the encounter is substantially or entirely complete.  

So avoid this pitfall by making sure that the relationship between your documentation system and your PM system is managed in accordance with good compliance practices.  Ideally, the encounter should be complete when the bill is rendered. If this cannot be your practice standard, you must do two things:
1. Make sure your system can reproduce the exact state of the documentation at the time the info is sent to the PM system. (That way you can make sure what you have completed supports medical necessity at least, and your system will support your assertion that it is sufficiently done at the time of billing to support medical necessity).
2. Make sure your system will not allow incomplete encounters to sit indefinitely. (Some systems force an encounter closed after a specified length of time or at a specific time of day.) After that, anything added will be an addendum and this is, in fact, the appropriate way to handle late additions, keeping in mind that one of the requirements for a medical record retaining its legal status is that it is executed in a timely manner.

Lastly, a big problem for practices that have in-house services such as labs or x-ray is the issue of "Open Item Billing". Some EHRs cue the billing for a test when it is ordered. If the test does not get done for some reason (patient declines, forgets, cannot urinate, whatever) the system does not know that the test actually was never done and may dutifully bill for a service that never occurred...

Most systems' odd behaviors can be mitigated by making sure you know how the system actually works and then adapt policies and procedures in support of all events occurring in compliance with medical records and billing rules.  There are other cautions in this area but that is enough to swallow at one gulp.

RDGelzer, MD, MPH, CHCC

Advocates for Documentation Integrity and Compliance

September 28, 2005

Copyright 2005 Advocates for Documentation Integrity and Compliance, LLC.

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