2018 CMS Guidelines for Physician Documentation and E&M Codes

Event Information
Product Format
Prerecorded Event
60 minutes
Product Description

Upgrade Your Physician Documentation and E&M Guidelines for 2018

As physicians, coders, auditors, and billers, you must ensure that the documentation supports the encounter. How is your EMR set up for documentation? Because if all the notes look the same or all examinations are the same for every patient, you run a high audit risk. And many other documentation pitfalls will set you up for a potential scrutiny, too.

It’s time for an upgrade to ensure compliance with 2018 physician documentation requirements. This is especially important in light of the possible changes to documentation CMS is proposing for evaluation and management (E&M) codes.

In this session, coding expert Melody Irvine will discuss the CMS Proposed Policy. She will also discuss CMS’s proposed E&M code changes. She will outline the specific areas CMS is looking at for documentation and how the new focus will affect future provider documentation.

E&M codes are always on the OIG Workplan, and you want to be able to protect your institution from unnecessary audits. After attending this session, you’ll be equipped to educate your team on possible trouble areas: spots where there is or could be over-coding of encounters.  And you’ll be an expert at spotting cloned-looking documentation that could send up a red flag with the feds.

Session Highlights

In this session, Melody will discuss:

  • Possible changes CMS is proposing for E&M documentation
  • EMR concerns for documentation
  • Risks as per the OIG Workplan
  • Cloned notes and other potential risks
  • Whether your providers are actually performing the services they have documented

Session Agenda

  • Documentation risks for providers
  • Importance of documentation
  • Principles of documentation
  • CMS proposal to change E/M
  • Area of high risk due to EMR Systems
    • Copy/paste
    • Cloning
    • Templates
  • Legal aspect of documentation
  • Risk adjustment
  • EMR Concerns
  • Medical Decision Making
  • Corrections/Addendums to EMR
  • Legal ramifications of incorrect documentation

Who Should Attend

  • Physicians
  • Coders
  • Billers
  • Office Managers



Important Copyright Information

Dear Valued Customer:


We have received quite a number of questions regarding the permissibility of copying and distributing our print transcripts, as well as questions regarding the conferencing of calls to other sites by our listeners. The main questions include:


May I photocopy my transcript packet and send it to others?

May I fax or email a copy of my transcript packet to one or more colleagues to use?

The quick answer to all of the above questions is “No.” If you or others you know are doing any of the above, you are infringing on the audioconferences’ copyright. Probably you weren’t aware this is a legal infraction, but it is, and it is punishable by law through damage awards, etc.


To explore low-cost alternatives for legally having more than one copy of this transcript, please contact our Customer Relations Department at 844-384-4744. Our representatives will be pleased to help while staying in compliance with copyright law.



Greg E. Lindberg



P.S. We trust that our audience of professionals such as you will respect our legal copyright “on the honor system.” But if we learn of willful violations, we may have to seek legal remedies.


P.P.S. If you know of any unauthorized copying or distribution of attendee packets or dial-in    information, please let me know about it in confidence so that we may follow up with the party and set them on the right path. (Your name will be kept confidential.)



2222,Sedwick Road Durham, NC 27713

Phone: (844) 384-4744 ~ Fax: (800) 508-2592 ~

Comment (R): I would like now to introduce your speaker for today, Melody S. Irvine.


Melody has 38 years of experience in the medical profession. She is the founder of Career Coders Online Medical Billing and Coding School. She's specializes in physician auditing and education and is an approved instructor with AAPC.


Her extensive background includes director of coding, auditing, compliance and urgent care for a 48 multi-specialty physician practice and previous contractor auditor for State of Colorado Attorney General.


Melody started her local AAPC Chapter and her scope as President, Vice-President and currently as education officer. She is a past member and officer of the AAPC National Advisory Board and is currently serving on the AAPC Board of Directors, as well as an AAPC Fellow.


She also serves on American Medical Billing Association National Advisory Board. Her true passion is teaching and motivated by career challenges. She resides in Loveland, Colorado.


Ms. Irvine, welcome to the program. We are now ready to begin.


Comment (MI): Great! Thank you for the introduction and I want to extend my welcome to everyone. I appreciate you taking time out of your busy day to join me.


This was my disclaimer that basically says this is not legal advice and each Medicare contractor are open to interpretation. Remaining for this presentation, indicate your acknowledgment and agreement with the disclaimer.


Now our agenda today, we're going to talk about documentation risks for our providers that are identified by OIG and CMS, also, the CMS proposals to the changing of the E/M codes. And, our areas of high risk with our EMR systems such as copy and paste, cloning and templates - all of these which has been addressed by OIG and CMS.


So, we will spend hour next hour discussing the CMS guidelines providers are expected to follow. Keep in mind, as some of these guidelines are not written in CMS guidelines but followed by CMS such as the CPT guidelines and ICD-10 guidelines. So – and basically, yes, they do follow them but some of them are written in CPT and ICD-10.


Also, examples that I give in this presentation – this is actual documentation errors that I have personally encountered. And, not all physicians make these types of areas but some areas – the providers – they just need to be aware of the documentation that can be considered a trend or a pattern which are things that CMS is looking for. And, puts them at a higher risk of possible auditor repayment.


I just want to basically tell you, last week, I heard an attorney that works for the OIG and she gave me some ideas. She's a – again, attorney for them – of things that OIG is looking at in CMS - violation of official coding guidelines. She talked about documentation that was inadequate to support of level services or billed. Code assignments that they were not billed on a claim form.


Let's see. She talked about services being billed to the wrong provider or incorrect Place of Service. That's been on the work plan many, many different times even the signature requirements, modifier usage, medical necessity.


Let's see. She talked about things know her billed, under billed, frequency for upcoding and denied services and downcode in services. All right.


So, what are your practice risks for your documentation?


Well, I'm going to talk about some of these risks and the common documentation areas and problems that we see. Remember that these are problems that are identified by OIG and can be under scrutiny with OIG and CMS as well.


I'll be showing you some of those common problems and again, these are things (normally) that I

have found as a problem but also that when I go in to a practice, these are things practice administrators, coders, auditors and other consultants have also identified with many of our EMR records.


 Now, CMS is – have a proposal and their proposal, it has to do with our E/M codes. These proposal came out in July of last year. And they want to reduce that clinical burden and improve the documentation in a way it could be more effective for our clinical flows and care coordination.


One of the focuses are really actually – two of the focuses they're going to be looking at is the history and the physical exam. Those are the two areas they're focusing on the most.


They're talking about the history. Talking about HPI where you need four or more in order to get an extended HPI and also the criteria for review of systems. What they are saying is that, they want to know if they should remove some of these documentation requirements and a physical exam for all E/M

visits at all levels.


One of the things, you know, when we talk about all others negative – we see that quite often. The doctors putting down all others are negative and it's not always medical necessary to do on all others negative on a system but it's very easy to click off in our EMR systems.


The other part of it though is any more we're not treating just the condition of the patient came in

for that day. We are now treating the whole patient and all of their diseases. So it does change a little bit of our E/M process as in the way we think about things.


So they’re also talking about the examination. You know, the examination – especially the ‘95 examination – people say we want more definitive answers of what is an expanded problem focused and a detailed examination, and for all the carriers to be consistent on what is expected of a ‘95 examination.

And I agree with that. I think it's such a gray area. Sometimes we're not sure how to code that area of it.


So basically it comes down to methodology of everything. How it's going to now changing a little bit because it's accommodating the value-based medicine that we're now performing. So, when will these changes be – come about? We're really not sure. I, myself, don't expect it this year but, I know it is in a work.


Now I know that they have tried ‘95 and ‘97 at combining them that is just – never did happen. So, maybe now with EMR systems things will change a little bit more and we will have a little bit better method of scoring our E/M codes.


So, why is documentation so important?


Well, per CMS, it must be a clear and concise medical record documentation, chronological care

of the patient, assist physicians and other healthcare professionals. And this is really an important statement because I hear from many different physicians to say, “By reading the previous note in this patient, I'm really not sure what transpired during that encounter. There's just not enough information. It's very vague”. And so we want to make sure that we have good continuity of care between physicians

about what transpired in the previous type of visits.


Also, it's auditing that's critically important too, to identify those problems before they become problem and, OIG does recommend it. It's not mandatory but I – it would help you in any type of audits by the government, payer or officials that you have been auditing their physicians.


So that documentation must be complete and legible. Documentation should include to the reason

for encounter, assessment, diagnosis, clinical impression, medical plan of care, date and legibility and identifying the observer. These are all in the CMS guidelines. As well as rationale for ordering diagnostic and ancillary services, past and present diagnosis. And, diagnosis and treatment supported in the medical record.


So good documentation – this will – it’s going to support and validate why our providers are charging the code that they are. Again, coming down to that good communication of writer, they will look at the past and be able to tell exactly what transpired during that visit.


Also, it's going to increase and recognize comorbid conditions, we know it's risk management.

This is more important. Validate care and the treatment as well as compliance in quality guidelines.


Now also, it will – there is a legal aspect to this documentation. And some of our attorneys are having a hay day with electronic medical records. It's – we want to make sure they understand all the legalities of it and the liabilities to the provider. They protect our providers against any – we want to protect our providers against any type of malpractice claims.


Our templates are creating more problems. And I'm going to show you some ideas of some of these in just a few minutes. And they need to document the thought process. Like when they used to dictate, they would have to think about what was going on and explain everything. Now, they rely too much in the EMR services but it doesn't always give all those complete thought processes.


So again, I talked before about risk adjustment. These are the reporting of those medical

diagnosis in order to bill the health risk profile for each individual patient. And this is information that’s used by HHS and CMS for claims data and patient demographic information. It helps to calculate that patient's risks score. Inaccurate of incomplete information will – by not reporting those chronic illnesses.

It's going to be a loss of revenue for our provider.


Now I'm going to talk about a little bit of EMR concerns that we have identified that was – that supports what CMS is saying of areas that they are checking and what is going on, and areas that are very high risk for these providers.


So, these EMR systems, they're great but it does has an awesome new set of errors and problems.

Things such as self or auto populating some of the fields. 


Copy and paste, we'll talk more about it as well as cloning of the notes. The templates themselves, they're not setup correctly. And if some of this is even compromising the healthcare of our patients.


Bottom line, many of this is affecting the integrity of the note. And things are just not used properly whether it be the way it was the system is setup which I have found in some of my auditing that it's not a provider problem, it's the way of their template or the way the software has been setup in their system.


Also, the other things we will talk about is some misspelled words or incomplete sentences. I'm sure we all see that as well as those blanks in the documentation, or just plain non-compliance with the organizational type of policies. Much of these, all boils down to padding the documentation as well because of the cloning, because of the easy to check off boxes and so it's making our code be over coded more than under coded.


So, one of the things we're going to first talk about is copy and paste. And of course, it has led to such errors, such as the symptoms, medications, histories, multitude of different type of errors even including misinformation.


And, one of the things I've been reading a lot about different loses have been going and many of

them has been because of the medication errors, just a multitude of different types of errors that is created because of the copy and paste.


So the question is, is it permitted?


Well, it is permitted. But, I would make sure you have a compliance plan written and the

guideline for using copy and paste. I think there's many providers that use it. Again, I don't have a problem with it as long as they are reading that information to make sure it is actually correct and the information is – has been updated.


This is what OIG says about copy and paste. They say, “When clinicians cut, paste or clone information without updating or ensuring its accuracy, incorrect – inaccurate information may enter the patient's medical record and inappropriate changes may be billed for the patients, and third-party payers.”

The OIG says, “A practice also could be used to create fraudulent claims.”


Now, we’re going to talk a little bit about cloned notes. And cloned notes, these are one of the thing that they are saying that – one of the new changes of E/M. The E/M is corresponds and not – does not correspond to the nature presenting problem.


So, it makes people believe once this actually done in the examination, again, adding padding. And, there's really no individualization to the exam along with the HPI. There should be some individualization of that so that they can add information to make it not look like a cloned note.


I see quite often in the same exam for every patient and after a while, (I’ll say) there's a little pattern to this and it identifies to me that may be these exams are templated too much of actually what has been done or was it really done.


So those cloned notes, they do create over documentation. Patients actually receiving more than

what that provider rendered and it's increasing liability too. So, higher level of services, that's what ending up with this and they don't support their medical necessity of lengthy notes.


That – the other thing is that OIG is identifying that the documentation is intentionally over

documented and so they're higher. They are getting a higher level of service therefore, it is constituting fraud.


This is what CMS says about cloned notes. They say, “Watch for cloned notes”. It’s right in their

information online. “Notes that appear identical for different visits, these may not reflect the uniqueness of the encounter or the patient's description of their chief compliant”.

I have an example. I had about 10 hospital patients, all with different illness and conditions. And, they will be things such as chest pain, abdominal pain, gangrene in the foot, pneumonia and all the exams were identical.


So that tells me there was not a lot of in to the look – analyzation that should have been such as a person that had gangrene. The examination says “skin clear” but they were obviously have gangrene of the foot.


Chest pain, no abnormalities in the cardiovascular exam. Those are just type of things that I see as a pattern that everybody's exam looks exactly the same. They’re in the hospital. There has to be some things that are not correct with the exam.


So here's an example of a cloned note.


Ears bilateral TM's pearly gray with good light reflex, EAC's are clear, external ears intact bilaterally non-tender. No mastoid tenderness or lymphadenopathy, no pain on manipulation, no gross hearing loss noted. 


Normal nose, normal nasal mucosa and turbinate's bilaterally. Eternal – external exam of the nose finds no abnormalities. No – oral pharynx no inflammation, tip – lips, teeth and gums intact. PND clear with no sinus tenderness on palpitation – palpation.


So, because of this – this is a template of 35 physicians. Seriously I thought they do a very thorough examination, but after a time and use of the template which was used by all of them and used the same thing.


So, further discussion with the providers when I asked them what that template indicates. I asked them, “What type of hearing test did they perform?” And none of them knew how to answer it. And even one doctors says, “Well, hearing is fine so we document hearing is normal”.


And it's interesting because after I realized that they had – one doctor actually changed his template to what was examined. Then I knew that these doctors were just clicking on the exam and not making it more individualized.


So, in this particular example here, they're getting six bullets for ENT, but did they really look at the external ear? Did they really do a hearing test? Did they look at the nose, teeth, lips and gums? (What are) some place something you do what every single visit? So I knew there had to be something wrong there was it. So really in actuality, there are like getting three of these six bullets. We started – and started looking at it a little bit deeper.


So there's other things I look at when I'm auditing is, what is a cloned note? Is it the same as everybody? There's probably a problem there. 


This one too I see. Constitutional look for an appropriate mood and effect. And then in the

psychiatric, orientation times three and intact judgment and insight.

Do we really need those three psychological examinations on every patient? No. Does the patient has dementia or some other problems? Yes, I can understand that. But for every single patient that walks through the door that's three extra bullets just in psychiatric as well as if you're using ‘97 and I just don't feel it as appropriate.


And sometimes they'll put some of these things in the neurologic when they actually go in the psychiatric area. So again, they're not thinking about the EMR system is setup – those template – to click that off but it actually it's only one point that’s documented many times.


So what is our cause and outcomes of all this?


Well, again, there's going to be a lot of conflicting information which I find quite often and I'm going to show some of that. As well as padding as exam and the review of systems not relevant to age or gender of the patient. It's being scrutinized more and more about the providers.


This OIG person that I heard talk about because that's one of the things I'm looking at is so much contradictory information because it is so easy to click off on some of the boxes.


Now here's an example of an incorrect template. It was 12-month-old, seen for fussiness and tugging at the ears. Examination of the ENT, GI, cardio, lungs, oriented times three, good judgment and insight. Diagnosis, otitis media. They gave them a prescription, instructed patient for safe use of meds, purpose, dosage, importance of finishing prescribed medication.

First of all, how does the provider exam a 12-month-old for orientation of time, place and person, as well as judgment and insight. That was the way the template was set up.


Other thing, instructed patients of safe use of the meds. No, they instructed their mother – patient

safe use of meds in purpose. So again, these templates are not always set up correctly for the age of the patient.


The other part that really concerns me is if a provider is signing off on it. They're obviously not

reading it or they would catch some of these type of things as well.


Drop down boxes. This has been a problem for several different things. Incorrect drugs, incorrect

allergies, incorrect genders, there's so many different things to indicate that also has caused problems with ICD-10 codes.


They're – to me, I feel that many times these ICD-10 codes are not built correctly in the system. They make it difficult for these doctors to find the codes that they're looking for because when we can't bill the unspecified which we don't want them to use. But just not set up correctly for the doctors to use the codes that they want to.


And we know what's ICD-10. There's so many more codes that what we had before. It's just not

set up properly. But it is important for them to verify, verify, and verify the information on these drop down boxes.

I had a personal experience with incorrect drug that I was allergic to and they select the wrong one. I was in the hospital at the time. And one of the things I think back that every person walked in the door should've verified that information of what I was allergic to. It was until like four months later that we found out that the wrong drug was in there. That should be verified every time the patient is seen especially by that provider or before any injection is given of what they are allergic to.


So again, just as I was talking about the ICD-10, it's just so difficult for those provider locating those correct codes. They're not specified enough. Incorrect codes in the same diagnosis. I know during one of my audits, I was talking to the providers about ICD-10 codes and have all select them in the drop down box, and even I had a hard time finding their correct code.


So by – just don't assume that their doctor's putting on the wrong code, it could be a software issue. And if it is, that’s something you needed – get it corrected or let them know with more specific diagnosis that they need to use.


Again, it all comes down to education of our providers. Just for your documentation, one of the common things I see is the Chief Complaint is not addressed. We don't need a separate Chief Complaint.

Medicare recommends it but it's not saying it is mandatory to have one. But even in that first sentence, I’m really not sure why that patient walk through the door.


So they might say, “Follow up for a Chief Complaint,” which is not a Chief Complaint follow up

for what. But even in the first sentence, patient is here for follow-up. I really don't know why the patient is coming in for a follow up. So making sure they identify why those patients are walking through the door, to make that appointment. It’s going to help support the medical necessity of why that patient came in that door and for the reason – for billing in the services.


The assessment identifies the diagnosis but it's not documented anywhere in the history. Well, I will have patients there come in for GERD or hypertension, but that patient actually came in for a sore throat. But nowhere (in the note had they) talk about or even to address that the H – and the hypertension was stable which would support the medical necessity. It's nowhere even addressed at all.


Also review of systems on every patient, we talked about this. And I do feel – do not feel it's medically necessary for all patients. Some physicians will argue about that. As long as they can support it in a court of law, I don't have a problem with that but they don't feel medically necessary for all patients.


Auto populating or carrying that information forward, not a problem. As well – as long it is  checked and rechecked. 


Contradictory information. Boy, I see this a lot especially with the review of systems and HPI or even in the examinations. Example of what I said a little bit ago when someone came in for a gangrene of their foot, and in their examination it says, “skin normal”. There is definitely some problems there. Too much contradictory information between the HPI and the review of systems as well.


HPI might say no wheezing and then the review of systems says “wheezing”. So I see that on just about too many times per day.

So here's an example of a diagnosis that was not addressed that I found. Sixty-three-year-old female patient presents with frequent urination, urgency, burning sensation and low back pain. History of previous UTI infections over the last year. She denied flank pain, fever or hematuria. Symptoms started over a week ago and gradually became worse. She has tried to drink more water but it is not helping.


So in her assessment, she – they have dysuria and asthma. Nothing was ever addressed in asthma, not that she had asthma. I had – it wasn't even in her medically history as asthma, yet they gave them a medication for asthma. It would not support the medical necessity of it.


This was another thing and I know it is not always understandable by the physicians but I want

them to understand how it can affect different things and that's the wording of personal history. 


Explain personal history – per ICD-10 guidelines. Explains the patient's past medical condition

that no longer exist and it’s not receiving any medical treatment and has a potential for recurrence.

Therefore, it may be required continuing monitoring. That is the personal history.


But many times it would say, “Personal history of diabetes.” Well, or a history of hypertension. Those are things that not – that do not go away. So if they need continuing monitoring, but they are still being treated for it. So it's not considered a personal history.


But again, I see that quite often that they make it as a personal history code when it's not a

personal history. Now if they look at that personal history and say it’s a problem with a diagnosis of a four-year diabetes client but not a personal history code. And again, it's going to be a concern with risk management coding as well.


Past, medical, family, social history. Making sure it's relevant to the age. I will see six-year-old does not smoke. Make sure that that past, family, social history matches the documentation. So an example on this one that noted in HPI – HPI patient has a long history of UTIs. But in the past medical history indicates no medical history of UTIs. Which way is it?


And this is some – much of the information from the history is carried forward. 


One of the things identified in one practice is that the NA was updating the past medical, family, social, history. But for some reason the doctor was – she was not clicking it correctly. And so the doctor, when they went to look at it, that information was not updated. It was – has this little glitch in their software system.


So when I noticed this, they went in and were able to get a change and made a big difference in how that medical record read.


Here is another one I found with past medical history. Patient indicates they take Tramadol.

Doctor indicates, “no past medical history or current medications”. Well, if they're taking Tramadol which wasn't – it was in HPI, why are they taking Tramadol? They must have some type of medical history. 


You could see where this could be a malpractice that they're saying the doctor was not really – somebody else is looking at it and said, “There's no medical history.” But there really was. There has to be a reason why they're taking Tramadol.


So padding the exam, especially on examination, those things we talked about. Doing hearing test on everyone, gait and station on everyone, external examination of the ears and the nose. Psychiatric, mood and effect, judgment insight, oriented times two or oriented times three. 


We will see this that is on every single notes. So we're looking for those type of things because that's exactly what Medicare and CMS and OIG are looking for these type of inconsistencies that every patient has the same thing.


And when I was talking to the OIG person, I asked her specifically, I said, “We see a lot of this.

And all the exams are the same.” And she does exactly – and it's going to down the road, create some real problems for them as well as attorneys would like this as well because it shows that every exam is exactly alike.


Also using things such as HEENT, don't say “HEENT Normal”. I need to know exactly what was examined in that examination of HEENT. Was it the head, eyes, ears, nose, throat? Things positive/negative. What did they find? So just, “ HEENT normal” is not appropriate either.


So here's an example of an examination. Chief complaint – this came from a hospital note. Chief complaint, altered mental status. HPI, patient has problem finding words and could not make sentences.


During the exam, constitutional, she is oriented to person, place and time. Neurological, she is alert and oriented to person, place and time. Psychiatric, she has normal mood and effect. Her behavior is normal. Thought content normal.


This – all is due through a template. And again, it was not double-checked by the provider. The

patient – when it was an HPI on the patient, basically they could not get any type of HPI or past, family, social history or even review of systems because of her mental altered status. There was nobody around to speak for her. So that information wasn't there but yet, the examinations are something totally different.

Huge, huge problem on risk area.


Here's another one, for medical decision making. Concerning 99215s and providers charging, way too many 99215s.


Last year, one of the OIG people were telling me in 2000 – it was then I guess in '17, $5.5 million already recovered by Medicare/Medicaid because of the 99215. It is a very high risk code. I have several providers that I have spoken about the 99215 charging it quite often, but their medical record does not support the 99215. And then of course, we can't use time on every visit as well.


Once we've spent the time educating their physicians about what is required for 99215, they then

changed their pattern. A lot of it was that they were trying to do something fraudulent, they were just not aware of what was required for 99215.


And just because the patient was sick and may be dehydrated in the office does not require a 99215. They walk out of the office, they were fine. Now that they could have done prolonged services with that and that's how I educated them that. Use your prolonged services. Not that all insurance is going to pay for it but at least it will be billed correctly.


The other thing was something can be based on time but every visit cannot be based on time as



This is a real high concern. I just had a provider the other day contact me that she's being audited for 99215. And I've tried to tell her that the year before that she was charging way too many 99215 and that her medical record was not supporting it. She didn't believe me and really didn't even understand what a '95 and '97 examination was but she continued with that pattern. Now she's in trouble.


So, you know, the only thing you can do is you can educate your providers about using two high

level of codes. But unless they're willing to have that education and how to protect themselves, there's not much you can do about it, except for one man. And I have it all in writing as well that I told her – I thought her services were billed too high.


And again, do I think she was fraudulent? No, I did not. I just feel it was an education process.


Speech recognition. This is also one – and this one, anybody went to conference, AAPC conference. This was brought up and it was kind of interesting. Some of our doctors use Dragon which is a speech recognition. And the word is pronounced the same as another but it has a different meaning, such as flower or flour, carrots or carat, two, too, and to. And it changed – it can change the medical record in the patient's condition.


So it was really funny because the girl came out, and she doesn't – we have a doctor that used Dragon. And some of things are coming up but he's not double-checking them, because she was asking the legal panel about this. 


And she says, one of the doctors dictated “pancreas” and in came out as “pan grease”. So – but the doctor didn't catch it. And she said it was funny but it doesn't meet the guidelines. And obviously the doctor didn't check it and signed off on it. So pancreas came out as pan – “canned grease”.


So again, we have to really watch at speech recognition especially if someone has a little bit of a

dialect. It can really – the word can come out a little bit differently.


So again, we want to protect those doctors to make sure that they're looking all – at all of that information.


Signatures. We need to remind those providers that electronic or hand signatures on all medical records indicates the information as accurate. And then medical record, it's true. Any type of ordering of medications or lab orders, or anything must have that documentation.


We have one provider in Indianapolis that was not signed in their cardiology. EKGs and it was $25 million suit for not signing hundreds and hundreds, and hundreds of different EKGs. So again, make sure that those signatures are on there.


Corrections and addendums to EMR. This is also been something that's been brought up by a problem of OIG. They – the corrections or addendums are not amended (appropriately) – cost the mistake for provider per CMS. Clearly and permanently identify any amendment, correction or delay entry. Clearly indicate that they – in author of that amendment, correction, or delay entry. And clearly identify original content without deletion.


One other thing you need to do is make sure that your software has a security program in place

for this. Make sure that they have it set up that the original information cannot be deleted. 


They – you have an ability to track corrections or changes. Do flags exist the notify that there was a corrected error or addendum for that particular note? Location and date of that error indicated such as the lab result, medical record, wherever it may be. Does a system time and date stamp corrections/addendums and the person that is making that correction and addendum. Very, very important.


Make sure, do not delete any information or hide information and do not black out any type of entry. You need to make sure that your software is set up correctly this way. Check with your software company and make sure these types of security programs are in place. It will save the doctors a lot of money if it's not done correctly – if it is done correctly.


One question I hear quite often is, can I change CPT and ICD-10 codes? Well, first thing you

have to look at is what is your written policy in place.


Do this – because it's more specificity or they're missing a diagnosis, diagnosis is not supported. I would not change anything unless you have an official writing from your practice or your facility that you can make these changes without the permission of the provider.


Again, unless you provide an official audit as well. Changing the E/M level not by just looking at it and doing an official audit before ever anything can be changed for an E/M level. You want to show the provider writings why it's support the different levels and what it does.


But yes, it would take somethings you can. Other things, you need to make sure you have a policy in place to support you're changing any information.


Also know your Medicare guidelines. Remember these OIG – these – your work plans and those type of things, they are focusing on audits and evaluation. They identify many of our risk areas and you should be evaluating them every year and make sure providers are not at any risk of these areas, such as your – keeping up with your CCI edits, LCDs, CPT, ICD-10, HCPCS, and making sure that you are auditing your physician.


I just can't stress it enough the possibilities of that we can identify by doing audit for the physician.


Such as this doctor I was talking about was doing too many 99215. If she would've let me audit her back a year ago, then we could've identify the problems and she couldn't make these corrections. Now she's with, you know, some pretty hefty fines to show that she's been billing all these 99215s when the documentation doesn't support it.

Order Now To Read Full Version Along With Conference Material

Order Below or Call 1-844-384-4744 Today

Order Form

(Select the format below)

Choose Quantity:

(*) Single User Price

You can also order through:




About Our Speaker

Melody S. Irvine - Medical Billing and Coding Expert

Melody S. Irvine, CPC, CPMA, CEMC, CFPC, CPB, CPC-I, CCS-P, CMRS, AAPC Fellow, has 38 years of experience in the medical profession. She is the founder of Career Coders Online Medical Billing and Coding School with a specialty in physician auditing. Her extensive background includes director of coding, auditing, compliance, urgent care and billing for a forty-eight multi-specialty physician practice as well as a previous...   More Info
More Events By The Speaker

Why ProfEdOnDemand?
  • Save money on travel.
  • Meet your specific training needs.
  • Keep learning after the event.
  • Save time training your whole staff.
Join Our Mailing List