Fear of EHRs being wrong leads doctors to code E&M services manually

Despite the fact that most electronic health record systems can assist physicians in assigning codes for evaluation and management services, most Medicare physicians still do it manually.

The Dept. of Health and Human Services Office of the National Coordinator for Health Information Technology asked the Office of the Inspector General to prepare a report looking at how Medicare physicians use EHRs to assign and document codes for E&M services. The report found that 57% of Medicare physicians use an EHR, and 90% of them use their systems to document E&M services. But most physicians still assign those codes manually, which could mean they are undercoding services that could qualify for a higher pay rate.

Susan Fenton, PhD, assistant professor at the College of Health Professions at Texas State University, said she is not surprised that more physicians aren’t using the code-assigning features in their EHR systems, despite those features being a big selling point.

Fenton said physicians don’t have enough trust in EHR systems to use the features that assign codes. She said HHS and the Dept. of Justice need to do some kind of certification of the coding capabilities and get them to agree that if something was coded incorrectly and physicians can prove they didn’t alter the software, doctors won’t be held responsible.

If fraudulent upcoding is detected, HHS and the Justice Dept. do not go after the software company, they go after the physician, she said.

The percentage of physicians using EHRs has increased significantly due to the meaningful use incentive programs that began in 2011. Practices can earn up to $44,000 per physician over five years from Medicare or nearly $64,000 over six years from Medicaid if they show meaningful use of EHRs that are certified for the program.

The OIG report found that of the 57% of Medicare physicians using an EHR at their primary practice location in 2011, 22% started using an EHR that year. Three of every four physicians using an EHR to document E&M services were using a certified EHR.

Something that is lacking in the certification process is “testing to ensure coding recommendations are consistent with coding guidelines and data entered,” wrote James L. Madara, MD, executive vice president and CEO of the American Medical Association, in a May 7 letter to the ONC. The letter was part of the public comment period on the ONC’s proposed rule on the 2014 Edition of EHR standards.

Dr. Madara wrote that the AMA recommends that the ONC include testing on coding guidelines in its certification process and that the ONC work with the OIG, the Centers for Medicare & Medicaid Services and the bodies charged with testing EHR products for certification to ensure that EHRs do not facilitate upcoding and that the feature is built into the certification process.

In a statement emailed to American Medical News, the ONC said its focus has been on clinical standards and addressing the low adoption rate of clinical systems that can improve the quality and safety of health care.

“There has historically been greater adoption of billing systems, so this was not seen as an area of focus,” the statement read. “That said, ONC is continuing to work closely with CMS to explore the electronic submission of medical documentation for claims purposes through our esMD Standards and Interoperability Framework initiative.”

The electronic submission of Medical Documentation Standards and Interoperability Framework initiative was launched in 2011 to look for new ways of submitting medical documentation to Medicare review contractors using standard, interoperable systems.

Fenton said it’s hard to know how manual code assignments are affecting physician revenue. The OIG report said E&M services represented 45% of the top 20 procedure codes billed to Medicare in 2010. If a physician is risk-averse, the doctor will undercode, Fenton said, with the thought, “Hey, they can’t come after me then.”

“If you do a cost-benefit analysis, it might be less expensive to undercode than try to deal with an investigation,” she said. But Fenton has found that there doesn’t have to be a large increase in coding levels to see a significant bump in revenue.