Beware of the Problem List in Compliance Audits

The problem list is a required feature of certified EHRs and must be used by providers in order to attest for Meaningful Use, starting with Stage 1.  Prior to Meaningful Use, problem lists were used inconsistently in the outpatient setting.  They have greatest value in primary care and are intended to highlight active problems that require constant monitoring and management.   However, many providers will add conditions to the problem list that may be inactive or only relevant from a historical perspective.

Many EHRs allow providers to import items on the problem list into the assessment or other sections of the note.  This has the potential to create a situation where problem list conditions that were not relevant to a given encounter appearing in the assessment and plan section of an encounter note.  EHRs do not have the ability to differentiate between items that were actively managed during the encounter and those that were not even mentioned.

If the provider elects to include problem list items in the assessment of the note as coded diagnoses, this creates problems in two areas:

  1. The additional ICD codes may be used to determine the level of medical decision making for the encounter.  For example, a patient with a history of migraine headaches may have this as a listed diagnosis on the problem list.  This same patient visits their provider for evaluation of low back pain.  The provider addresses the low back pain during the visit but no mention is made of migraine headaches in the history or physical examination sections of the note.  The provider then elects (or the EHR automates) inserting items from the problem list into the assessment section of the note.  No further information about the diagnosis of migraine headaches is entered by the provider.  The diagnosis of migraine headaches then becomes part of the MDM level determination, even though the provider did not address that problem during the visit.  If this behavior elevates the level of E/M service falsely for the encounter the fee for the encounter may be denied by the payer.
  2. The provider may order procedures based on problem list items that appear in the assessment.  For example, a provider pulls forward the problem list and incorporates it into the note, and one of the items is a diagnosis of Hypothyroidism.  No information regarding the hypothyroidism such as symptoms, finding or signs is documented in the record.  The provider then orders a thyroid ultrasound study based on the problem list item that was brought forward alone.  This is considered potentially fraudulent activity.

Summary and Recommendations:  Pulling items from the problem list directly into the assessment, a feature supported by many EHRs, is not recommended, unless the provider exercises a great deal of caution when determining the correct E/M level of service.  If this approach is taken, the provider must ensure that the clinical record contains comments specifically on the status of the condition.  The provider should also make sure that the medical decision making component of E/M is not influenced by ICD codes that are redundant or irrelevant.  Lastly, no procedures ordered can be based upon problem list diagnoses unless there is active documentation that the condition was addressed during the patient visit.

The information provided on this page, unless otherwise referenced,  represents the opinions of its author, Michael Stearns, MD, CPC

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