Mike Enos, CPC, CPMA, CEMC and Nancy Enos FACMPE CPMA, CEMC, CPC-I, CPC have authored a series of articles published in MGMA's Connexion Magazine.  The September issue features the first part in the Code of Conduct Section, and Part 2 will be published in October.

The importance of medical necessity is always the most important component is selection of an E/M level. The features in many EHRs can create auto-text and complete checklists, leading to documentation of elements that were not actually done.

Cloned notes (using the exact same verbage from patient to patient), copied notes, and automatically generated notes should be examined closely, and physicians should be trained on how to delete, correct, and authenticate the contents of their notes to ensure that the notes actually reflect the services provided to a particular patinet, and nothing more.

EHR's that have a "coding tool" can be especially risky, when the level is calculated based on data elements, and not medical necessity.

CMS has approved complex audits of high level E/M services, following their May 2012 Report on improper billing and coding of high level Evaluation and Management Services. 

Connolly has today posted on their web site their new audit scope related to E&M audits:

http://www.connolly.com/healthcare/pages/ApprovedIssues.aspx

Impacts: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia.