Happy Holidays: Update Your EMRs and Review Your Procedures

Updating electronic medical records (EMRs) will allow for electronic signing and dating.

New Medicare regulations became effective Jan. 1, 2020. Per the Centers for Medicare & Medicaid Services (CMS) news release:

“To reduce burden, we are finalizing broad modifications to the documentation policy so that physicians, physician assistants, and advanced practice registered nurses (APRNs, to include nurse practitioners, clinical nurse specialists, certified nurse-midwives, and certified registered nurse anesthetists) can review and verify (sign and date), rather than re-documenting, notes made in the medical record by other physicians, residents, medical, physician assistants, and APRN students, nurses, or other members of the medical team.”

The real rub will come in the implementation. Physicians and physician groups will have to modify their electronic medical records (EMRs) to allow for the electronic signing and dating of medical records.

The new regulations do not mean that all requirements for documentation are eliminated. Healthcare professionals will need to make sure that the underlying note supports all the elements required for billing. They will also have to try to make sure that the notes are made by medical professionals who are competent enough to make and enter the note in the first place.

I am particularly thinking of notes made by interns and residents working on elective rotations. The reason the resident is working in the physician’s office is to increase their level of competence. It would seem reasonable that residents and other medical staff are sufficiently competent to take patient histories. What about the review of symptoms? I think of concern are the things that patients share with their physicians, based on the personal and trusting relationship they have created. 

Finally, since most EMRs drive documentation and usually suggest billing levels for physicians, is the software used by physicians and other professionals designed to make sure that the signing and dating of medical records are detailed enough to support proper billing under the Medicare program?

As an example, a comprehensive examination must include at least nine organ systems or body areas. For each system/area selected, all elements of the examination should be performed, unless specific directions limit the content of the examination. For each area/system, documentation of at least two elements identified is expected. 

In signing and dating the notes of other professionals, it will be necessary to make sure that their notes are complete – and signing and dating the note may require that each element required also be signed and dated. 

I think all professionals billing Medicare need to do some homework over the holidays.  Bah and humbug.