Fraud, 21st century-style

First, though, I would like to share a discussion we had this weekend about fraud. When I first started teaching coding 13 years ago, many physicians were worried about committing fraud. They were taught that if they were guilty of fraud, then they could have to pay back the money, plus up to 3 times in penalties, plus possible jail time. All of this is true. But most of their fears were unfounded.

Many of them had the following dilemma: I think I just wrote a 99214 note. I feel that I should bill for a 99214. But did I put in enough 'stuff'? Is there enough Review of Systems? Enough Social or Family History? What about Exam bullets? Data Review? Most of what doctors were afraid of was not technically fraud. Rather it is what is known in auditing as 'incomplete documentation.' You are honestly writing an accurate note, but you may have left out something that is required for a particular CPT code.

Let me share with you a much more dangerous thing that is occurring on a daily basis now in medicine: Many of you have an EMR system that allows you to click or check a box saying that you reviewed the past Medical, Social, or Family History. Or even worse the Review of Systems. Then your EMR copies and pastes the entire text forward into your note. This is not good. In fact, many times, this is actually fraud. Let me explain why.

It is good medical practice to review the patient's medication list and reconcile it every time you see them. This should appear in the past medical history (PMH) section of the note. Same thing for their current problem list, and also their current medical allergies. These 3 things are part of doing good medical care. And I believe when you put these in your note that you have reviewed them with the patient.

But what about the other parts of PMH that automatically 'roll forward' with your EMR. Did you really review the entire surgical history with the patient again today? Did you really review the entire Family History? You may have done the smoking questions, but did you do the entire Social History? I had a doctor ask this weekend: "Well I don't use those parts of History as credit in my coding since I didn't really do it, but my EMR rolls it forward anyways."

What?!?!?!?! You just put things in your note that you did not confirm. Legally that is the same thing as lying! That is the definition of fraud! Whether you tried to get 'credit' for it from a coding standpoint does not matter! Even if you billed only a 99212 visit, you committed medico-legal fraud by putting something in your note that you did not do!

Never ever ever do that again! Never let your EMR do that again! I hope you understand the gravity of what you are doing when you write and sign your name to those 8 page notes. It is much better to put a partial PMH that says "NKDA" or just lists the meds. Leave out the old Social History and just put in "Nonsmoker" today if that is all you did today. And unless you reviewed all 10-14 systems again today, absolutely do not let it come forward into today's note. It will never help you and is much more likely to hurt you in an audit or legal proceedings.

A small concise note explaining what you did today and only what you did today is the accurate, ethical, and legal thing to do when practicing medicine.