Article Discussion: Concealed Improper Billing in EHRs

This informative article (link below) discusses EHR features that may lead to inaccurate documentation and billing that may be more “concealed” than traditional fraud potentiating features such as cloning and over-documentation.  It was published by and authored by Marla Durben Hirsch with a primary contribution from Dr. Reed Gelzer.

Five EHR features discussed in the article that may lead to fraudulent documentation are summarized below.  I have provided additional commentary based on my 14 years working with EHRs and EHR users in areas of documentation and compliance.

  1. EHR features that prompt providers or coding/billing professionals to add additional documentation that that will increase the level of the code.
    • Comment: This is an excellent point and from my own experience this has been requested by providers in the field as an EHR feature.  However, this practice has been specifically banned by CMS.  In addition, it is not legal for coding/billing professionals to alter the medical record without the knowledge, consent and then signature from the physician/provider.
  2. Templates that contain preformatted text that leads to over-documentation or approximations that the provider feels are “close enough” in the words of Dr. Gelzer, who was a principle contributor to the article.
    • Comment:  I discussed this same topic in an article published in June of 2014 in the American Association of Professional Coders Monthly Business Journal titled “Dangers of Imported Texts in EHRs” that addressed templates and other forms of “imported text.” Templates make it far too easy to import entire sections of a note (e.g., and normal ROS and a normal PE).  I have witnessed this practice in the field and have counselled my fellow physicians about the consequences of their behaviors.  Nonetheless, the level of temptation given a busy clinical environment makes accepting templates defaults too easy.
  3. The lack of EHR’s ability to demonstrate when it has been altered, which could allow modifications to be made the lead to higher level of coding
    • Comment:  With the advent of Meaningful Use certification, audit logs became mandatory in EHRs in order for them to be certified. However, EHR vendors took a variety of different pathways as to how they approached this requirement, including how long a document could be left “open” before the audit log would flag it as being audited. By rule any modifications to the clinical record must be addressed through an addendum, but the consistency and range of coverage varies between software vendors. CMS has been pushing for standardization of audit logs, and EHR audit logs are increasingly being used in malpractice cases.
  4. The ability to disable audit functions in EHRs (for the stated purpose of reducing storage and data processing costs).
    • Comment:  As noted by Dr. Gelzer, this is no longer a valid reason for disabling these functions.  From personal experience this is a feature that helps in the sales process, as some providers do not wish audit logs to be created based on their activities.  Making audit logs that cannot be turned off is the current direction of movement in the EHR industry, but some vendors still allow this feature.
  5. “Problems with source attribution.” Dr. Gelzer discusses the problems with a template being created that is used several times again for different patients.
    • Comment: It was not entirely clear if he was referring to the process of cloning a note on one patient and using the same note for a subsequent patient, or the generic process of using a template several times during the week for similar patient encounters.  EHRs that provide the ability to use a note created for a patient to be used verbatim for another patient do create risk of “source attribution” as Dr. Gelzer describes.  Information entered on one patient may be striking similar to information captured during an encounter with another patient (e.g., a young patient with a viral upper respiratory infection), however, there are essentially always differences, some of which may be clinically essential to patient care (e.g., duration of symptoms, presences of fever, immunization history, etc.)

In summary this article illustrates a number of very valid points that need to be taken into consideration by EHR users. CMS, the OIG, the FBI and audit contractors are rapidly gaining in their awareness of features of EHRs that can lead to fraudulent documentation.  What was not discussed in this article where the marked variations between the automated coding tools that are found as features of many EHRs.  Findings based on in depth evaluations of the automated EHR coding tools from 4 leading EHR vendors were reported in this article: Study Finds EHR Coding Tools Lacking

Link to full article in Much improper billing is well concealed – EHR fraud prevention: What providers and payers must know.

The commentary provided in this article represents the opinions of the author of this post: Michael Stearns, MD, CPC.



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