Coding consultants explain where the risks are and how to avoid them.
April 20, 2007, Ken Terry, Medical Economics
It’s long been known that physicians tend to code higher for office visits after they get EHRs. But now Medicare and private payers are taking an active interest in this trend, and audits of computerized practices are becoming more frequent. So if you have an EHR, be very careful how you code, say coding consultants.
Joan Gilhooly, a consultant in Deer Park, IL, cites the case of an internist who was billing “a substantial number” of level 4 visits. A Medicare audit showed a pattern of nearly identical information in all of the records reviewed in his EHR. This physician appeared to be documenting a complete physical, a review of systems, and a family and social history in every encounter. He was potentially facing not only a civil charge of upcoding, but also the possibility of criminal fraud charges. Fortunately, his lawyer managed to establish that none of this was intentional: The physician’s poorly trained staff had simply pulled in information from previous records for the doctor to consult when he saw each patient. So in this case, the government settled instead of going forward with the case.
Gilhooly tells this story to caution physicians against purchasing EHRs in order to increase their revenues. That may be a side benefit if they’ve been undercoding all along, as many doctors do. But that isn’t why they should buy an EHR, she says. Vendors who promise that physicians will see a big return on investment from more appropriate coding, she maintains, just aren’t paying attention to the Medicare coding rules.
Those rules, which set the standard for private payers, do not equate coding level with volume of documentation, she stresses. While EHRs help physicians document better, she says, “it still boils down to problem severity. If there’s a mismatch between severity and the level of service, as calculated by the volume of documentation, they shouldn’t bill that higher level of service.”
Virginia Martin, a consultant in Waterville, OH, says she’s done internal audits of EHR-equipped practices that documented comprehensive exams and past histories when patients visited for minor problems. “The medical decision-making is really what determines the level of care; the history and the exam should be appropriate to the presenting problem,” she says.
Having staffers take most of the history is one reason why documentation goes awry, she adds. “Staff members can perform certain portions of the patient encounter, and they should not go beyond that.”
Overdocumentation can also be related to how a physician uses an EHR, Martin points out. If a physician implements the system without customizing the EHR templates to his practice style, “the templates may contain more information than what he’s used to documenting. So it appears that the history and the exam are more complex, but the medical decision-making level is low.”
Martin and Gilhooly both advise physicians to spend time building their templates. “Be brutally honest with yourself,” Gilhooly adds. “Saying that you typically do an eight-organ system exam on every patient who walks in the door isn’t being honest with yourself.”
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