Bowman acknowledges that EHR set-up can lead to the appearance of upcoding, but says that deliberate over-billing is a rarity. "There are concerns about EHR features and the way they are used that may inadvertently cause problems in patient care and billing," she says. "The ease with which information can be copy and pasted from other parts of the record, or from different patient records, can inadvertently make the patient look more complex or suggest a more comprehensive physical exam than was true for that specific patient."
The pitfalls, however, have not been lost on the compliance-sensitive industry, Bowman says. "Providers and hospitals are stepping back, establishing policy and procedures. They are working with EHR vendors to put in some restrictions so these features cannot be indiscriminately used-the copy and paste features are not by themselves inappropriate, but if they've used excessively or incorrectly it can cause unintended consequences."
Bowman also agrees with Atwal that under-billing was routine prior to EHR deployments. "There has been a lot of under-billing in the past due to incomplete documentation," she says. "But there are other variables driving up reimbursement. Patient conditions are becoming more complex. Just because reimbursement is higher doesn't mean it is wrong or fraudulent." She calls on HHS to conduct more research in the matter.
The HHS letter caused many in the industry to bristle. "The letter was an unfair assessment of how the vast majority of physicians are utilizing EHRs," says Lyle Berkowitz, M.D., medical director of information technology and innovation at Northwestern Memorial Physician Group, a Chicago-based primary care group practice of 120-plus physicians. Since 2002, the group has been documenting on an ambulatory EHR system from Cerner, with billing done via interface to another system. "EHRs do indeed enable more appropriate coding. But just because that may result in higher coding, it should not be assumed to be upcoding."
In his primary care practice, physicians see many patients with multiple chronic conditions, Berkowitz says. And thanks to the efficiency of the EHR, they are able to accomplish more in a single visit, heeding alerts and reminders that a patient may be due for a test or evaluation not related to that particular visit. The work performed at the practice is categorized under an "evaluation and management"-or E&M-coding system which assigns individual visits to a certain level, with 1 being the lowest and 5 reserved for the most difficult cases. Assigning the right level is driven by a complex, multi-tiered formula that includes the extent of the exam given, the history reviewed and overall medical-decision making.
"E&M codes are specifically designed to help account for the cerebral 'thought work' we do," Berkowitz says. "If in 15 minutes we can help a patient control their diabetes, hypertension, cholesterol and heart diseases, we should be appropriately compensated. It's very hard work." Berkowitz adds that if the same patient winds up needing heart surgery, a surgeon would be paid much more for their time. Future reimbursement models will begin to even out the disparities, he predicts.
Because primary care physicians can do more in a visit with an EHR in place, their coding levels may, appropriately, go up, Berkowitz says. "In the old paper-based system, if a patient came in with an ankle problem, we would often deal just with that one issue and tell them they need to come back. Now the EHR allows us to be more efficient by allowing us to address more issues in the same amount of time. If a patient with ankle pain is also due for diabetes and hypertension follow-up, we can take care of that right then. We address multiple issues in one visit and document all that. In the paper world, I might do two 'Level 3' visits and now I do one 'Level 4' visit. So I'm saving the government money."
Part of the efficiency of the EHR rests indeed in its ability to bring forward previous charts and findings. For example, the chart automatically updates lab values, vital signs and test results to show the most recent findings during the encounter. "We do pull forward the old note, but we update and edit it," he says. "In the paper world, it was easy to flip back and look at old charts. In the electronic world, think of the note as an evolving Wiki. I can see what I did last time and document what I am doing today."
Berkowitz adds that his practice's EHR note system includes a clearly marked area called "Problems Below Not Addressed." Any issues not taken care of during a visit are denoted in that section to clarify that the encounter did not cover it. This helps the practice avoid billing for services not rendered. It also helps with the next visit by identifying potentially lingering issues. "We are very clear about what we do and do not address" during an encounter, he says. "But we also want to ensure we have a holistic view of the patient's medical issues so we don't miss anything either."
Some experts say that the key to proper billing rests in the way the EHR is set up in the first place. "The implementation of EHRs can pose some risk due to their ability to let users copy and paste notes or auto-populate data fields," says Mary LeGrand, a consultant with Karen Zupko and Associates, a Chicago-based firm which advises on proper coding and billing practices. "The strength of the EHR is that it can capture work not previously captured in written documentation. That's of significant value. EHRs themselves are not 'bad' in this regard. It comes down to the implementation."
Pulling an entire note forward does pose risks, LeGrand says. If an identical exam template shows up in subsequent notes and the findings are identical, it raises two questions, she says. First, is there medical necessity to do the same exam in every visit? And second, were the findings really identical, or were they just auto-populated results?