“I have a normal exam template that I always use.”
All right, I know baseball season is over, and it is hunting season in Vermont, so maybe I should title this, “Don’t shoot yourself in the foot.” The government and private payers have cloned notes in their line of vision. And, physicians and Non-Physician Practitioners (NPPs) can make it too easy for the payer to challenge an EMR note. How?
- The same history and exam for every patient.
- An exam that doesn’t make any sense for that patient. Today I read a note that documented a follow up visit for otitis on a 7 month old patient. I was surprised to see that the patient’s carotid arteries didn’t have a bruit and there was no JVP.
- Copy and paste: we’ve talked about this before.
- A sameness to the visits. Print out ten notes and you can predict which systems will be examined in the ROS and what the exam will look like, regardless of the presenting problem.
- Contradictions: we’ve worried that topic to death.
I have two observations to make about all this. Physicians sometimes blame us for their EMRs. “You made us use these systems.” “Health information tells me that has to be in the note for meaningful use.” Health information won’t be responsible for the repayment if a payer comes calling. No one in health information has a provider number: the clinician’s provider number is on the claim form. Take responsibility for both the information and the format and insist on a format that makes clinical sense.
Somehow, I missed the memo, but coders have become the queens and kings of the universe. But, we coders don’t have provider numbers either. Avoid developing an attitude. Insisting that MDM is a stand in for medical necessity is not a helpful response to the type of errors I’ve listed above. Education and feedback are helpful responses.