EHR templates could cost providers reimbursement dollars

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There's been a lot of press of late about investigations into electronic health records and billing fraud by the U.S. Department of Health & Human Services, the Office of the National Coordinator for Health IT and the Office of Inspector General. But there's been scant attention to a government initiative that will affect many more providers, including honest EHR users, and hit them where it hurts: in their reimbursements.  

The Centers for Medicare & Medicaid Services now is on the warpath against the use of EHR templates to document progress notes.

The agency quietly instructed its contractors last month to change the way they review pre- and post-payment claims. The instructions, called Transmittal 438, Change Request 8033, focus on ensuring that providers have sufficient documentation to support claims. Contractors now must consider all permanent medical record entries, even those entries created using limited space templates, and extract any usable information relevant to a claim. Gone are the days where review contractors could consider "any" documentation to support payment determinations.

These revised instructions, effective this week, specifically target the use of inappropriate template shortcuts in EHRs.

CMS states that it doesn't prohibit the use of templates, but discourages templates with limited options, such as predefined answers, checklists and ones with limited documentation space. The agency goes on to say that "review contractors shall remember that progress notes created with limited space templates in the absence of other acceptable medical record entries do not constitute sufficient documentation of a face-to-face visit and medical examination."

What's notable is that unlike the saber rattling by HHS, ONC and OIG, CMS' new requirements have received relatively little fanfare, even though they impact many more providers than just those being investigated for fraud. Sure, the revised instructions are available on CMS' website, but they're buried under Regulations and Guidance. Moreover, there was no announcement accompanying the revision, and very little press coverage.

CMS contractors will start applying the new instructions to all provider claims; unsuspecting providers with inadequate documentation in their records will start receiving payment denials they weren't expecting.

What's even more interesting is that while the revised instructions are directed to the payment review contractors, the transmittal tells providers what kind of templates should and should not be used. CMS also warns providers that templates designed to gather only "selected information primarily for reimbursement purposes" won't cut the mustard.

The agency then shoots a cannonball across the bow, informing providers not only that they may not get paid, but that insufficient documentation may trigger "further review."

What this really means is that a lot of providers who rely on the templates in their EHRs are about to get a rude awakening.

Ted Doolittle, Deputy Director for CMS' Policy Center for Program Integrity, specifically noted in a speech to attorneys at the American Bar Association Health Law Section's annual Washington Summit last week that most providers are providing healthcare in an honest fashion, and that government officials "don't want to catch dolphins in the tuna net."

But if providers don't know about this increased scrutiny of their templates--the right templates to use, and which ones to avoid--they won't know to double check their template use and make sure it complies with the revised requirements.

Now might be a good time for CMS to speak up. - Marla