A peer-reviewed, evidence-based journal for clinicians in the field of neuroscience
Issue link: https://innovationscns.epubxp.com/i/555782
Innovations in CLINICAL NEUROSCIENCE [ V O L U M E 1 2 , N U M B E R 7 – 8 , J U L Y – A U G U S T 2 0 1 5 ] 34 QUESTION "I am considering implementing a new EHR system. According to the vendor's marketing material and the salesperson, the EHR system will increase my revenue by automatically increasing the documentation required to support the higher level E/M codes. Is this too good to actually be true?" ANSWER You are right to be concerned. You should focus on creating accurate documentation rather than creating documentation that supports higher level coding for services that are not medically necessary. The goal should be to document your decision-making so your work can be understood by others, such as subsequent treaters, or even expert witnesses supporting or questioning your care in litigation years later. RISK MANAGEMENT STRATEGY #1: DOCUMENT WHAT YOU DID AND WHY, AS WELL AS WHAT YOU CONSIDERED BUT REJECTED AND WHY Say you have a patient with suicidal ideation—you document that you think he should be hospitalized and that voluntary hospitalization was offered to him, but he declined. You also document that you considered involuntary hospitalization, but the patient didn't meet the criteria. Further, you document that you adjusted the treatment plan—maybe changing medications, increasing the frequency of visits, requiring the patient to check in by phone, and discussing your concerns with the patient's significant other. You explain in your documentation what you did and why. The Florida Board of Medicine is one example of a licensing board that has put this expectation into a regulation that states "A licensed physician shall Risk Management This ongoing column is dedicated to providing information to our readers on managing legal risks associated with medical practice. We invite questions from our readers. The answers are provided by PRMS, Inc. (www.prms.com), a manager of medical professional liability insurance programs with services that include risk management consultation, education and onsite risk management audits, and other resources to healthcare providers to help improve patient outcomes and reduce professional liability risk. The answers published in this column represent those of only one risk management consulting company. Other risk management consulting companies or insurance carriers may provide different advice, and readers should take this into consideration. The information in this column does not constitute legal advice. For legal advice, contact your personal attorney. Note: The information and recommendations in this article are applicable to physicians and other healthcare professionals so "clinician" is used to indicate all treatment team members. EHR DOCUMENTATION: How to Keep Your Patients Safe, Keep Your Hard-Earned Money, and Stay Out of Court by Donna Vanderpool, MBA, JD Innov Clin Neurosci. 2015;12(7–8):34–38