EMR audit pitfalls

The use of electronic medical records (EMRs) for keeping patient records has become the norm rather than the exception in BC. EMRs are not only a fundamental component in keeping patient records, but also how physicians submit billings to the Medical Services Plan (MSP) for services rendered. Before EMRs were implemented, physicians used paper charts to keep patient records and a billing software to submit their billings to MSP. It is becoming more common for physicians to use one system for both tasks. 

The Patterns of Practice Committee has a few audit tips for physicians who use EMRs.

The billing field
The billing field in the EMR is not the patient record. The billing field simply represents a claim submitted to MSP, similar to an invoice. If the Billing Integrity Program (BIP) or Service Verification Group (SVG) requests patient records, such records are considered to include consultation reports, progress notes, or operative reports. These records should demonstrate evidence that the service provided met the billing rules for the fee item claimed. Neither BIP nor SVG asks for, or accepts, copies of your billing field as evidence that the service provided is consistent with the fee item billed. 

Likewise, if you are audited, it is the patient’s record that comes under scrutiny and the medical inspector will look to see if the fee-item criteria had been met.  

If a fee item has a requirement, for example, a start and end time, you should ensure it is in both the billing field and the patient’s record. 

Fee codes
Do not rely on your EMR to look up the most appropriate fee code to bill. The EMR does not know if you meet the criteria to bill that fee. Always refer to the payment schedule and the preamble to ensure you are billing the appropriate fee and meeting the criteria. 

Allowing your EMR to set defaults, such as automatic billings for patients, can lead to billing for patients you may not have seen. Defaults should be used as a reminder to bring patients in for follow-up or care plans, not to bill automatically. 

Additional resources
For information beyond being aware of the audit pitfalls noted above, review the following documents from the CMPA and the College of Physicians and Surgeons of BC (CPSBC) for more information on good practice guidelines pertaining to EMRs.
•    CMPA. Documentation: Electronic medical records (www.cmpa-acpm.ca/serve/docs/ela/goodpracticesguide/pages/communication/Documentation/electronic_medical_records-e.html)
•    CPSBC. Professional standards and guidelines: Electronic Medical Re-cords (www.cpsbc.ca/files/pdf/PSG-Electronic-Medical-Records.pdf)

—Lorne Verhulst, MD
Chair, Patterns of Practice Committee$

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This article is the opinion of the Patterns of Practice Committee and has not been peer reviewed by the BCMJ Editorial Board. For further information contact Juanita Grant, manager, audit and billing, Physician and External Affairs, at 604 638-2829 or jgrant@doctorsofbc.ca.