I appreciate getting notes from specialists. Really. It’s great to be kept in the loop with patients’ care, especially when other doctors are using EMRs that directly fax me notes the same day as the visit. Sometimes, though, things can get a little out of control.
I’ve ranted before about offices that use templated EMRs to generate documentation of things they never actually did. Today I received the following letter:
Reason for the appointment:
1. Abdominal pain
2. Post colonoscopy with biopsyHistory of present illness:
1. Abdominal pain: he failed to show up for this appointmentCurrent medications:
[med]
[med]
[med]Past medical history:
[problem]
[problem]
[problem]
EGD 2008 negative, EGD 2011 negative, colonoscopy 2005 normal
2010 Chest CT with 3 mm lung nodule, low riskSurgical history:
Appendectomy age 24Family history:
Non-contributorySocial history:
Tobacco: non-smoker
Machinist, married, no childrenAllergies:
PCNHospitalizations/Major diagnostic procedures:
DeniesAssessments:
1. [problem]: appropriate ICD-9 code for [problem]
2. [problem]: appropriate ICD-9 code for [problem]
NO SHOWPlan:
1. OtherElectronically signed by I.M.Schmuck MD
Sign off status: Completed
That’s right. If you read that carefully (hint: I highlighted the relevant parts in red), you will see that this entire note (which satisfies documentation guidelines for the history for a level 4 office visit) was generated FOR A PATIENT WHO WAS NEVER SEEN. Silly me. I always thought documenting a history implied that you had actually spoken to the patient. Maybe he’s in the hospital with a heart attack. Maybe he is now allergic to sulfa. Maybe he’s newly divorced and has taken up smoking again.
This document blows my mind. It is Exhibit A in how not to use an EMR. I have nothing against templates, and in fact have come to use them on a daily basis. Then again, I only use them to avoid repetitive typing of short phrases, not entire documents. Come on, people! This is the sort of crap that lets patients and pundits ridicule us so mercilessly.
If nothing else, I also have surprisingly little sympathy for doctors who complain about paperwork when they turn around and generate a 2-page note for a No Show.
Geez!
Musings of a Dinosaur 
let me guess….they use nextgen?
By: runlikeallhell on February 23, 2012
at 4:19 pm
Yes… it is crap..
Yes… the “physician” who sent this out and signed off on it is less than credible.
But.. no.. This does not come close to being a level 4 office visit. There is no HPI (past the complaint), ROS, or even an exam. There is no medical decision making… not to mention the fact that there isn’t an encounter at all. Sheesh. This doesn’t meet any level of billing.
So..Autofill gone crazy, or M.D. without any sensibility? Let’s call people to the carpet for bad behavior. But let’s not blame the computer for the egregious act caused by the individual. In fact, it deters from the true problem with EMRs. The fact that they remain more of a tool for administration than for clinicians. The fact that they have horrible usability and create more work, not less. The fact that we are documenting things that simply don’t need to be documented for any reason other than to satisfy a level of billing.
EMRs could be exceedingly great and useful, if only we stopped paying for the dogfood that’s continues to be served to us.
JFS
By: JF Sucher, MD FACS on February 23, 2012
at 4:28 pm
What happened here is fairly obvious. The note was initially created based on the schedule and some key points were put in with the remaining history, exam, and actual diagnosis and treatment to be filled in.
The patient then didn’t show up.
The note is left in the computer and the doc doesn’t know how to delete notes once they have been made so he just signs it to get it of his to do list. He doesn’t realize that all notes get sent to the primary.
There was no deceit or laziness or otherwise involved here beyond not knowing how to delete a note once started.
If it wasn’t this, it was something similar.
And agreed with JFS. This note doesn’t meet 99212 let alone level 4.
By: JustADoc on February 24, 2012
at 10:28 pm
If you years ago you wrote a blog about lack of security on DEA numbers. Physician credentials like DEA, NPI, and license numbers are issued by the government, and they are publicly available, but there is no systematic way for you to track how your credentials are being used. Would you pay $10 a month for a service that worked with pharmacies, insurers and benefit managers to give you feedback on how your credentials were being used? Side benefit would be the ability to see who actually filled their prescriptions.
By: David States MD on February 25, 2012
at 8:42 am
A few years ago… (the perils of auto correct)
By: David States MD on February 25, 2012
at 8:48 am
What your example shows is that the software designer failed to account for a fairly common event, patient missed an appointment. Since the physician never saw the patient they should never have been asked to sign off on the chart. Receptionist or scheduler should have been able to simply click “no-show”.
By: David States MD on February 25, 2012
at 9:44 am
[…] too often game the system. Our favorite dinosaur provides this important note – Auto-Fill Gone Crazy. In this post she describes the gaming that computer programs […]
By: Gaming billing codes — db's Medical Rants on February 27, 2012
at 7:07 am
Unrelated to this post but wanted to make sure you saw it. Sleeping pills are associated with a 3 to 5 fold risk of death and may contribute to the deaths of up to 500,000 Americans a year. 6.2% of the patients in the Geisinger Health System on sleeping pills died in the study period, a mean of only 2.5 years:
http://bmjopen.bmj.com/content/2/1/e000850.full?sid=2d5fb123-d2db-4735-a64d-fc8f46ffed9f
By: James Wilk on February 28, 2012
at 10:39 am
Did they actually bill for this “encounter?”
By: JPB on February 28, 2012
at 12:12 pm
Agree with (nearly) all of the above. What I meant by “meets coding guidelines for a level 4 visit”, what I meant was after doing the HPI and exam, adding everything else in this non-note was enough to buff it up to a level 4.
I don’t believe any deceit was intended. Clearly it’s a software bug that either doesn’t allow deletion of an entry when the patient doesn’t show, or laziness on the doctor’s part for signing it to close it out. No, I don’t believe they billed for the non-encounter.
As for “gaming the system”, the problem is more the system than anything else. Subject of my next post. Stay tuned…
By: notdeaddinosaur on February 29, 2012
at 2:53 pm
Can;t wait to read what’s coming next. As BIlling Compliance leader in my department and long term member of our college’s Compliance committee, I’ve been on the front lines of the EMR vs good coding and documentation war for over a decade now.
It’s a war with many battles to come.
If our experience here as a relatively early adopters of the EMR is any indicator, the tide may be turning for the forces of good documentation. Hopefully that will happen before the Medicare Auditors enter and declare themselves victors.
By: tbtam on March 5, 2012
at 1:39 pm