The proliferation of electronic medical records (EMRs) has generated a situation that really roasts my beef, and I am seeing it with increasing frequency. It's the flip side of the lawyers' old canard,
If it isn't documented, it didn't happen.
It seems that more and more doctors are taking that to mean that if something IS documented, then whether or not it actually happened is moot, at least as far as payment is concerned.There are at least two specialist offices who regularly send me letters documenting examinations that I know for a fact did not occur. In one case, the proof is that they document procedures requiring a level of patient cooperation and vocalization incompatible with the patient's age. (ie, How do you get a two-year-old to tell you in which ear the tuning fork sounds louder?) In another, a full body exam is documented at each visit when only the affected limb was examined. Those are the only two where my level of certainty is 100%. There are many others that are highly questionable, but harder to prove because of patient unfamiliarity with examination procedures.
In the paper days there were innocent examples like PERLA (now when was the last time you really checked the patient for accommodation?) as well as some more creative forms of writing. Paper based templates pushed the envelope of fraud, but the EMR became the great enabler.
Examples like those cited above may range from carelessness (to take advantage of the speed of the template generated note you neglect to go back and edit stuff out) to deliberate, thoughtful abuse. In either case you can bet your coding department will bill for what’s in your note!