College of Medicine Office of Compliance, Gainesville, Florida
COMPLIANCE TIP -

Ambulatory and Inpatient Epic Electronic Health Record
Compliance Do's and Don'ts list

KEY TAKE HOME MESSAGE: You are responsible for the entire content of your documentation.

• Entries carried forward from a previous visit(s) must be reviewed for accuracy and edited appropriately. Be sure system phrases represent what happened in today's visit and clinical data that was not done in today's visit is clearly indicated. It is not appropriate to carry forward information if it is not pertinent to the date of service rendered.
• Be sure the history of present illness and Review of Systems agree (when using templates/smartphrases and checkboxes to generate review of system documentation.
• Do not use any functionality that presets all unanswered items to "no" or defaults to "no".
• Action by provider required in documentation. Do not use templates to prepopulate entire Review of Systems or Exam sections with "canned" negative findings that do not require positive action. Positive action can include checking a box, selecting from macros and templated documentation, typing freetext, or selecting from a drop down menu.
• Know what this checkbox/statement means! "Mark as Reviewed" are checkboxes that occur through Epic applications, and "I have updated/confirmed the history" can be found in templates. They mean - "I have confirmed this documentation with the patient/patient's family".
• AMBULATORY, INPATIENT and ASAP (Emergency Med) Do not copy/use any portion of a Medical Students note other than Review of Systems and Past/Family/Social History. Federal regulations are clear that only the portion of a note originally authored by a medical student that can be used in support of a bill are the ROS and PFSH sections of history. A resident, ARNP, PA, or physician copying the medical student note does not meet re-documentation requirement.
• Do not copy documentation from another author without proper notation and attribution to the original author. This includes reference to the date, time and author of the original entry. Failure to properly attribute authorship has the potential risk of becoming a federal or state false claim, including fines and penalties and criminal liability to the individual.
• Notes must reflect all practitioners' services. When you combine a note with an ARNP/PA, the medical record must be able to identify that you saw and evaluated the patient, reviewed the note, and include patient specific information provided by you. Do not remove any references to the ARNP/PA's participation in the service. It is recommended that the ARNP/PA reference their participation within the body of the note.
• Keep in mind that viewing the information while on line in the Epic environment may look considerably different than the printed record. It is this printed note that will be provided to outside users such as payors, federal and state agencies to support your service. Check your printed notes.
• You are responsible for the review/comment on any lab results and other studies imported into your note via any means (template/copy functionality). Delete those that are not pertinent or not medically necessary.
• Just as is the case with paper records, when billing based on time, do not combine time with resident or ARNP/PA. Be sure to include total time, time spent in coordination of care, and the topics discussed with the patient or patient's family.
• No chart-to-chart copying between patients. Ever.

AMBULATORY ONLY

Make me the Author (MMTA) - is a copy function that changes note authorship to your name so you may electronically sign. MMTA was designed by Epic in response to requests to provide a consultation letter. There is an audit trail of authorship. While the resident's name cannot be seen on the final version of an MMTA note, using MMTA *does not* remove your obligation to append your teaching physician statement if a resident was involved in the service.

There are two steps to getting to Make Me the Author. First the "edit" button, and then the "Make me the Author". If you stop on "edit" and do not proceed to "Make me the Author", the authorship does not change to you, and you cannot append a proper electronic signature.

• Do not rely on E&M level guidance provided by Epic Ambulatory. Level of Service guides in Epic use -97 guidelines only, while '95 guidelines may be more advantageous.

INPATIENT ONLY

• You must confirm the Patient history dropped into your note via Smart-links. Many notes open and automatically populate your physician note with past, family, social history that is already in the medical record from previous encounters, and may be information gathered by a nurse. You must state in your note that you have reviewed the information with the patient/patient's family.
• Critical Care: Just as with paper records, resident time does not count in billing critical care time. Do not combine critical care time of attending and ARNP/PA. Attendings within the same specialty may combine critical care time and report it in the billing number of the attending with the preponderance of time. The attending would personally provide his or her statement of total time, time spent in counseling/coordination of care and topics discussed with the patient or patient family.
• The hospital problem list is only maintained in the problem list section. When using templates that import the problem list into your physician note, keep in mind the link only flows one way. If you identify a new problem and include it only in your note, it does not flow back to be included on the central/shared problem list.

Documentation patterns that are determined to create risk to the College can potentially result in suspension of billing.

Questions?

Contact the Office of Physician Billing Compliance for the University of Florida, College of Medicine, Gainesville Campus
Phone: (352) 265-8359 or e-mail: nwt@ufl.edu

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