CMS: Do EHRs lead to upcoding?

The Medicare agency is probing whether physicians are using paperless systems to bill costlier services, but doctors say EHR complexity is the real problem.

By Charles Fiegl amednews staff — Posted May 13, 2013

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The accuracy of physician documentation has been scrutinized for years, but a relatively new focus of complaints involves how doctors use features of electronic health record systems to support their claims. Concerns that doctors are taking advantage of EHR automation to bill higher-level services — intentionally or not — are misplaced, physicians said during a May 3 forum at the Centers for Medicare & Medicaid Services headquarters.

Federal lawmakers and CMS officials have encouraged physicians and hospitals to adopt EHRs by offering financial incentives and threatening eventual cuts to Medicare payments. Health information technology can provide clinical support, allow sharing of records across care settings and offer other functions, such as drug formulary checks. EHRs are viewed as an asset in new care and payment models.

But the technology can be a double-edged sword. CMS lately has become concerned about the unintended consequences of EHR adoption. Auditors and lawmakers have suggested that recent increases in the rates at which doctors bill costlier, higher-level services could be attributable to the enhanced billing capabilities provided by EHRs.

Jonathan Blum, CMS deputy administrator and director of the agency's Center for Medicare, stressed that the program's own data don't yet point to evidence of such a correlation, but he noted that CMS was looking into the matter. “We have begun efforts to study whether there are differences in coding patterns for those who have adopted EHRs versus those who have not.”

In the meantime, physicians say they find themselves whipsawed by pressure to adopt EHRs on the one end and accusations on the other that those same products allow them to game the system. One example of the phenomenon involves the EHR templates designed for certain specialties or patient encounters that physicians use to save time.

“Templates serve as prompts and guides to remind health care providers to document information that may not previously have been written down or dictated into a note,” said Steven A. Wartman, MD, PhD, president and CEO of the Assn. of Academic Health Centers. “One of the goals of increasing the use of EHRs was to increase the accuracy of documentation. The use of a template to encourage this increased accuracy does not deserve to automatically be flagged as fraud and trigger a [recovery audit contractor] audit.”

EHRs not seen as paragon of efficiency

Instead of seeing EHRs as generators of easy windfalls for physician practices, many doctors perceive the new systems as barriers to success.

“Attempting to transform the entire health system in such a rapid and prescriptive manner has compelled providers to purchase tools not yet optimized for the end users' needs and that often impede, rather than enable, efficient clinical care,” said Steven J. Stack, MD, chair of the American Medical Association Board of Trustees, during the CMS forum.

The real problem with EHRs lies in how physicians have had to incorporate them into their practices, Dr. Stack said. The task has been frustrating and difficult, because physicians often find costly systems unhelpful as they painstakingly navigate through various prompts to complete simple tasks. Doctors taking part in a Medicare or Medicaid EHR incentive program since 2011 also must follow criteria to demonstrate meaningful use of paperless systems, which has had unintended consequences, he said.

Many physicians report dissatisfaction with EHRs as they try to bring them into practice. A 12% decrease in satisfaction was noted between 2010 and 2012, with nearly four in 10 clinicians stating they would not recommend their systems to colleagues, according to a recent survey by AmericanEHR Partners, an organization formed by the American College of Physicians and Cientis Technologies. The AMA also is part of the group.

Medical records once were designed only for writing findings and decision-making processes for doctors' personal reference and communication with other physicians. Over time, the records' purpose has expanded as a tool for dealing with coding, billing, compensation, compliance and litigation, Dr. Stack said.

“Widespread adoption of EHRs … in combination with the progressive shift toward team-based care — both things which we would assert are good — are rapidly and dramatically changing clinical documentation,” he said. “Documenting a full clinical encounter in an EHR from scratch at a single data point at a time can be pure torment.”

The exercise in frustration is made worse by the work flow processes required by the nascent EHR systems, Dr. Stack said.

“Each element is selected by a series of clicks, double-clicks or even triple-clicks of the mouse,” he said. “Standardized language, not necessarily intuitive or ideal, is presented for all items being documented. Hunting, clicking and scrolling just to complete a simple history, physical exam is a tedious and time-wasting experience.”

Possibly, bigger bills from more details

Complaints from users about the frustrations of EHRs notwithstanding, concerns from payers about increases in billing intensity don't appear to be waning.

The administration convened the May 3 session to gather more information about the issue. CMS' Blum said his agency recognizes that its own coding guidelines and payment policies might be part of the problem. Medicare is considering revisions as the health system shifts to one relying less on paper records.

But some see recent changes in billing patterns not as a sign of unwarranted upcoding enabled by paperless systems, but as a legitimate accounting of services.

Before widespread use of EHRs in clinical practices, doctors and other health professionals often were concerned about possible accusations of fraud and abuse if billing codes were not deemed supportable by the medical documentation, said Lisa Gallagher, vice president of technology solutions at the Healthcare Information and Management Systems Society. Because of this, physicians anecdotally had undercoded for certain patient encounters when doctors were not certain of the appropriate complexity of the services, she said. By taking some of the guesswork out of the process, EHRs may be enabling more physicians to bill more accurately.

Patients also may be requiring more intense services. The American Hospital Assn. published a May 2 study concluding that Medicare beneficiaries are coming to emergency departments with more complex conditions. For instance, the average severity of illness for a patient increased by 9% from 2006 to 2010. Medicare patients also are seeking emergency care at a higher rate, as patients using ED services at least three times in a year increased two percentage points to 15.5%.

“This trend in severity of illness that we are seeing in the emergency room is actually real as opposed to just a result of people gaming the system,” said Benjamin K. Chu, MD, the American Hospital Assn.'s chair.

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Ways to improve EHR documentation

The American Medical Association has offered possible solutions to problems with electronic health record adoption and the relationship among EHR documentation, coding and billing. At this point, it's not reasonable to criticize physicians struggling to comply with EHR adoption, said Steven J. Stack, MD, chair of the American Medical Association Board of Trustees. The AMA suggested that:

  • EHR usability concerns raised by physicians be addressed by incorporating usability in federal certification requirements.
  • Clear and direct guidance be provided to physicians on EHR clinical documentation for the purposes of coding and billing.
  • Dialogue with the physician community continue so documentation and billing guidance does not affect patient care adversely.
  • Stage 2 of the federal meaningful use program be reconsidered to allow more flexibility to meet requirements while EHR systems are adapted to accommodate a variety of practices and work flows.

Source: Testimony of AMA Board Chair Steven J. Stack, MD, at a forum held May 3 by the Centers for Medicare & Medicaid Services on EHRs, coding and billing

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Upticks in complex patient visits

Physicians are billing higher rates of high-intensity evaluation and management services, says the Dept. of Health and Human Services Office of Inspector General. Physicians say the trend reflects better coding education and increases in the portion of Medicare beneficiaries with chronic conditions, among other reasons. The higher the final number in the code billed, the more intense — and costlier — the service. Figures represent the percentage of services billed.

New patient visit E&M code 2002 2004 2006 2008 2010
99201 5% 4% 3% 3% 2%
99202 24% 22% 21% 19% 13%
99203 38% 40% 42% 43% 37%
99204 24% 26% 26% 27% 35%
99205 9% 9% 9% 8% 13%
Established patient visit E&M code 2002 2004 2006 2008 2010
99211 6% 5% 5% 4% 4%
99212 15% 12% 11% 10% 9%
99213 54% 53% 51% 49% 46%
99214 22% 26% 30% 33% 36%
99215 3% 3% 4% 4% 5%
Emergency department visit E&M code 2002 2004 2006 2008 2010
99281 1% 1% 1% 1% Less than 1%
99282 8% 6% 4% 3% 3%
99283 30% 28% 25% 22% 20%
99284 31% 30% 29% 29% 29%
99285 30% 35% 40% 44% 48%

Source: “Coding Trends of Medicare Evaluation and Management Services,” Dept. of Health and Human Services Office of Inspector General, May 2012 (link)

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External links

Forum held by the Centers for Medicare & Medicaid Services on electronic health records, coding and billing, May 3 (link)

“Sicker, More Complex Patients are Driving up Intensity of ED Care,” American Hospital Assn., May 2 (link)

“Coding Trends of Medicare Evaluation and Management Services,” Dept. of Health and Human Services Office of Inspector General, May 2012 (link)

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