The letter-sent to the American Hospital Association, Federation of American Hospitals, Association of Academic Health Centers, Association of American Medical Colleges and National Association of Public Hospitals and Health Systems-sent a shockwave through the industry. HHS said it would step up monitoring of claims for any inappropriate activity, including "cloning"-or copying and pasting certain portions-of medical records from one visit to another. "We will not tolerate fraud," it said.
The topic of upcoding-the practice of assigning a higher level of service to physician work or a higher degree of severity to a patient diagnosis than is warranted-is a long-time industry discussion point, one that predates electronic health records. Yet, many industry experts contend that while upcoding may happen, it is more a result of complex billing rules than anything else.
But linking EHRs to fraud? That was a charge that many in the industry find hard to swallow. Ironically, these experts say that any increase in reimbursement is not due to fraud, but rather due to the better documentation that EHRs enable. Yes, copy and pasting of records occurs, they acknowledge. Yet the practice by itself is not necessarily borne of malicious intent-which many contend is the litmus test for upcoding-as much as it is maximizing the very technology the government is attempting to incentivize through its meaningful use program. Nonetheless, coding and billing experts cite several steps that providers can take to work toward compliance with the thicket of reimbursement rules.
Perplexed and perturbed
Money Atwal is one industry leader who admits to being both perplexed and perturbed by the HHS letter (CMS did not respond to written questions about the letter). He's well-situated when it comes analyzing the link between EHRs and billing-Atwal serves as regional CFO and CIO for the Hawaii Health Systems Corp., which runs three hospitals, including Hilo Medical Center, a 276-bed facility. The three hospitals receive about 44 percent of their payments from CMS with the remainder coming from several commercial plans. "I'm not surprised that overbilling is being discussed," he says. "At HHS, they just see that Medicare reimbursements are increasing substantially. But you don't need an EHR to game your bills. I would like to see HHS factually support its contention."
Like many of his peers, Atwal cites improved documentation facilitated by EHR technology as driving the increased reimbursement. Essentially, the argument goes, physicians and hospitals alike have long left money on the table by not documenting their work. Once EHRs are implemented, documentation capture-and charge capture by extension-improves, sometimes dramatically.
"Before the EHR, we used Post-It notes and would rely on nurses to manually document what they did," Atwal says. "We missed charges. There was huge variation. Now, with an EHR, it's easier to track. When the nurse hangs an IV bag, we can document the start and stop times. We can alert the nurse they did not chart the bag. In the manual world, we did not even know if IV bags were being given or documented."
That's just one small example of how EHRs can help with better charge capture, Atwal says. His hospitals are using an integrated system, from Meditech, for clinical documentation and billing on both the inpatient and ambulatory sides of the organization. With some 40,000 annual emergency department visits and 10,000 inpatient stays, the three hospitals gross about $325 million annually-a number that has edged up with the EHR in place. "We have seen an increase in charge capture, which led to higher reimbursement-about $1 million more per month in cash," he says.
Atwal monitors the cash flow closely at the three hospitals, hiring outside consultants to do random samplings of claims to make sure everything is compliant with billing rules and regulations. He says the hospital takes compliance very seriously-erring on the side of caution if anything. The hospitals employ seven coders who assign billing levels based on documentation in the EHR. "We review charts across the clinics on the professional side, the inpatient side and the ED," Atwal says. "We want to make sure there's no 'rogue coder' " inappropriately inflating claims."
If anything, the hospital may still be under-billing for its services, Atwal contends, due in part to being cautious about the long arm of the law that casts a shadow all the way from Washington, D.C. to Hawaii. "We identify lost opportunities. We have not maximized our coding. We have not coded consistently to what the diagnosis is and that is because of fear of retribution and penalties." Atwal estimates that the health system is still losing "hundreds of thousands" by not documenting IV injections as thoroughly as it could. "Even with the EHR, the biller is only as good as the documentation given to them."
Few would argue with Atwal's contention that EHRs yield better reimbursement. "EHRs do not facilitate overbilling per se," says Sue Bowman, senior director of coding policy and compliance at the Chicago-based American Health Information Management Association, whose 64,000 members include coders and billers. "EHRs help produce better documentation so the coding should be better too. How much increase in reimbursement is due to fraudulent documentation versus better documentation is an unknown."