EMRs & The False Claims Act
According to the Department of Justice, The False Claims Act establishes penalties of $5,000 - $10,000 plus treble damages for anyone that "knowingly makes, uses, or causes to be made or used, a false record or statement to get a false or fraudulent claim paid or approved by the Government." That's $10,000+ per claim!
Some Electronic Medical Records (EMRs) have features that cause substantial portions of the preceding visit note to be carried forward into the current visit note. In many cases, this results in a visit note that is full of information that is not reflective of the current visit. The documentation guidelines establish that only the Review of Systems and the Past/Family/Social History (PFSH) from a previous note can be used to support the level of service reported for the current visit. To secure this credit, the documentation guidelines establish that the following standard must be met:
"A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by:
• describing any new ROS and/or PFSH information or noting there has been no change in the information; and
• noting the date and location of the earlier ROS and/or PFSH."
Because of this standard, carrying forward ROS and/or PFSH into the current note without establishing that it was reviewed and update or without documenting the date and location of the excerpted visit note is not appropriate. It is more problematic when objective exam findings are carried forward because there is no provision that allows this.
This ties in with The False Claims act because a visit note that is coded based, in part, on documentation that is not valid will frequently be over coded (i.e. a False Claim). If that claim is audited by Medicare, the submission of the visit note to the auditor would be a False Statement.
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