Many providers have touted the electronic health record (EHR) as the magic bullet to improve billing accuracy. However, according to the Center for Public Integrity, “Medicare regulators also acknowledge they are struggling to rein in a surge of aggressive — and potentially expensive — billing by doctors and hospitals that they have linked, at least anecdotally, to the rapid proliferation of the billing software and electronic medical records. A variety of federal reports and whistleblower suits reflect these concerns.”
In the ‘paper world,’ physicians document the visit note and then generate a billing slip or superbill with the codes represented in the documentation. Pre-printed diagnoses are either checked off for the patient’s visit, or if a particular condition is not listed, the clinician writes it freehand on the form. With regard to procedures, here too, the most common ones are pre-printed on the form and checked off by the doctor. It is rare that a provider adds a procedure to the billing slip. This document is routed to the biller for processing. It is important to note that the biller’s role is to process billing information and follow up on outstanding payments, not to assess the accuracy of the clinician’s documentation.
In the ‘EHR world,’ the clinician generally completes a series of templates for the visit which, depending on the software, may include areas for typing free text about the patient’s chief complaint for the visit. Templates are a double-edged sword as they can provide a checklist reminder of all the components to address during the visit, and also speed the documentation process. However, they can also be faulty and facilitate errors in the assessment, even encouraging the documentation of visit components that may not have been done or warranted by the patient’s chief complaint. Females evaluated for prostate issues and males whose exams include areas of the female anatomy are not unusual; inconsistencies are also frequent as in the case of a patient diagnosed with a UTI whose exam reveals no findings consistent with the diagnosis.
In addition, some EHR systems allow for copying and pasting of information from a prior visit into the new visit note; identical or substantially similar notes across the visits raises flags among payors and regulators. Despite these concerns, here’s the feature most providers love: the system assigns or suggests visit codes based on the information that has been documented. Many clinicians assume the software assigns the correct codes and especially, assigns the most appropriate level of the visit which determines the reimbursement.
For example, the difference between a Level III visit and a Level IV visit involves differing components of the physical exam and visit complexity. Their reimbursement differs by $35.44 (2012, Broward county). However, the distinction between the visits is not solely based on the documented activities, but must involve the medical necessity of the visit as documented by the clinician. So in essence, performing a comprehensive Level IV visit examination on a patient whose chief complaint is hypertension under control could be over-coded by the software.
Although the majority of physicians do not knowingly engage in fraudulent documentation and billing, the Office of Inspector General (OIG) targeted potentially inappropriate payments for Evaluation and Management Services in its 2012 Work Plan. One can bet that regulators will continue to scrutinize provider payments and the role of EHRs in over-coding or inappropriate payment. The most optimal scenario involves a clinician who evaluates the data ‘proposed’ by the EHR program and validates the information and then subjects it to an independent review by a professional coder to assure the coded information is accurate.
Regardless of whether the software program assigned a billing code or the clinician completed a billing slip, the physician is responsible for the information transmitted to a payor on his or her behalf. For this reason, providers should assess their practice’s coding and billing activities on a regular basis by submitting to audits by certified coding professionals. A solid compliance program and remedial education for clinicians will go a long way toward mitigating potential fines and continued payor scrutiny.
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