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  • Verify, Then Trust Technology

    A pop quiz question in this year’s Codequest™ asked participants if they thought that “my [electronic health records are] designed for ophthalmology, and the templates provide all the necessary documentation per payer policies” was true or false.

    The correct response was false. Surprisingly, it was not selected by everyone. But in fact, a best practice is to always verify what your EHR documents, especially when it comes to coding and billing. Payers’ requirements constantly change and the system isn’t always correct in offering codes.

    During our private consulting services sessions, you made the American Academy of Ophthalmic Executives® coding and reimbursement team aware of several EHR documentation concerns. Here are some of them:

    Physician Order for Testing Services

    All payers require an order for delegated testing services. It needs to state the exact test, which eye(s) and the covered diagnosis. EHRs routinely require capture of the interpretation and test reports, but many do not have a built-in prompt for required documentation. For those that do, documentation needs to be available if audited.

    For additional information about how to bill and code for testing services, visit the links below.

    Missing or Incomplete Procedure Note

    You must include a procedure note for any minor or major procedure performed in the clinic. The documentation requirements vary by procedure and payer. Find an example of what Medicare payers require for an intravitreal injection in the retina documentation checklist. When it is there, the EHR documentation is often incomplete or contains wrong information. Some errors can be traced back to templates that are either integral to the EHR or input with mistakes and then duplicated. Mistakes include incorrect medication dosages, wrong number of units and inaccurate diagnoses linked to the procedure (see diagnosis descriptions below). Check all templates and make timely corrections when requirements and information are updated. 

    Copy and Paste Errors

    Mistakes happen when you copy and paste information in the EHR. It can turn one mistake into a recurring cascade of errors. If a procedure is performed on a new patient in one eye but documented erroneously for the fellow eye, it can continue unchecked and copied forward in the documentation summary. There is the potential for contradicting documentation not only on that date of service but in documents for every subsequent visit. A policy not to copy and paste will help you avoid and protect against its misuse, as outlined by the Centers for Medicare & Medicaid Services words of caution about cloning


    Upcoding, also known as “code creep,” is when the EHR recommends a higher CPT code than what was performed. This is related to the potential documentation overload problem created by cloning or copying and pasting. An example of this is when EHRs do not recognize “note bloat” or unnecessary documentation, in that it is not pertinent to the service provided at that date of service. EHRs often erroneously suggest a higher evaluation and management (E/M) code with a corresponding higher reimbursement based on all, even superfluous documentation. When these errors lead to improper payments, participating physicians are required to return them. 

    Diagnosis Descriptions

    Finally, do not trust the description of each diagnosis without verification. Many EHRs have a quick view option where you can check the diagnosis code and get a quick description of the code by hovering over it with your cursor. These quick displays may omit crucial details about the diagnosis code, for example, if the code contains the word “unspecified” or does not specify laterality, and you can get a major error. 

    Remember technology is only as good as the humans who run the system. Verify your documents for accuracy before final physician signoff and billing.