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The operations management team in healthcare practices is expected to have an effective coding compliance program in place that is continually evaluated and reevaluated. To accurately assess the program’s effectiveness, several outcome indicators must be measured, including error rates in the provider’s documentation and the electronic health record (EHR). Due to increased scrutiny by the Office of Inspector General (OIG), whose function is to supervise and guard the integrity of the Department of Health and Human Services (HHS) programs as well as protect the beneficiaries of these programs, physician practices must examine and evaluate risk areas.
The OIG report, Improper Payments for Evaluation and Management Services Cost Medicare Billions in 2010, gives clear instructions for the Centers for Medicare & Medicaid Services (CMS) to educate providers on coding and documentation requirements for E/M services, and to continue to have CMS contractors review E/M services billed for high-coding physicians as well as continuous review of E/M services that are paid in error.1 Due to the findings in the report, contractors initiated various programs to monitor documentation requirements for E/M services and, due to high error rates, began issuing prepayment reviews through the comprehensive error rate testing (CERT). Prepayment audits are costly to provider practices, because claims are not paid until they go through a comprehensive review. The OIG also indicated in the report that the most common documentation errors were caused by the copy-and-paste functionality in EHR systems.
In 2014, then OIG Inspector General Daniel Levinson suggested that guidelines should be developed for using the copy-and-paste feature in EHR technology. He further recommended that CMS direct contractors to use audit logs for investigations and provide additional guidance on detecting fraud in EHRs.2 The report and its findings called for the CMS to do everything in its power to prevent and stop the fraud and abuse that undermine the innovation of EHRs in the healthcare industry and risk overpayments from the Medicare budget.