LeGrand suggests that practices conduct baseline audits of service levels prior to EHR deployments. That can shed insight into the billing levels before and after the implementation. Moreover, the auto-population feature needs to be controlled by physicians, she says. If it can't be modified easily, it should be shut off, she recommends.
But shutting off the auto-population feature may undermine the very efficiency a practice is seeking with the technology in the first place.
"Physicians say if they turn off the feature and can't easily import data from previous encounters, they have lost the value of the EHR," she says. "You need a mix. You have to use information that was in the chart. Auto-population is OK as long as you customize each visit."
Customizing each note with each encounter is a key to avoiding fraud charges, adds Deborah Robb, director, physician Services, at Trust HCS, which provides coding consulting and outsourcing services. Robb agrees that increases in reimbursement have been driven largely by improved documentation offered by EHRs.
But she cautions against the practice of copy and pasting notes, lamenting the fact that some providers are even encouraged to use the practice as part of their hospital documentation. "How can you justify medical necessity when a note is identical to yesterday's?" she asks. "Every note should stand on its own."
The problem of cloned notes typically surfaces more in the hospital setting than a clinic setting, Robb says. And even though coders may assign the codes, based on the documentation provided by the physician, they can't always tell if a note is virtually identical to its predecessor. But pulling forward certain elements is important, she adds. "Hospitals need to develop policies about what are the acceptable parameters" for copying past notes, she advises, particularly when it comes to ancillary services, lab values and radiology results. "You should not have to rewrite what the lab did. That is valuable to pull forward. At the same time, compliance departments should say what is acceptable."
For many, the very complexity of health care billing undercuts any assertion that providers are over-billing. In its response letter to HHS, the American Hospital Association decried the lack of coding standards. "Since April 2000, hospitals have been using the American Medical Association's Current Procedural Terminology evaluation and management codes to report facility resources for clinic and ED visits," the AHA wrote. "Recognizing that the E/M descriptors, which were designed to reflect the activities of physicians, did not adequately describe the range and mix of services provided in hospitals, CMS instructed hospitals to develop internal hospital guidelines to determine the level of clinic or ED services provided. In 2003, the AHA and the American Health Information Management Association recommended that CMS implement national hospital E/M visit guidelines based on the work of an independent expert panel comprised of representatives with coding, health information management, documentation, billing, nursing, finance, auditing and medical experience.
"In the 2004 and 2005 OPPS rules, CMS stated it would consider national coding guidelines recommended by the panel. However, to date, CMS has not established national hospital E/M guidelines."
The AHA response is on target, says Robb, the consultant. "We don't have a standard health care system," she says. "Every facility develops its own policies, compliance and implementation. I would never just state that providers are up-coding."
For Robb, the root of physician confusion lies in the difference between hospital facility billing and physician professional service billing. Hospital reimbursement is largely driven by the DRG system, which assigns a global payment for facility services based on the patient's diagnosis and severity. In contrast, physician work is reimbursed in a separate channel that measures work output and complexity of decision-making in the evaluation and management of patients. Thus the rules and implications of such practices as copy and pasting may have entirely different ramifications, she says. "You have such diversity between what a hospital can do and a clinic," Robb says. "Physicians are getting a lot of mixed signals. What is OK to do on the physician side may not be on the hospital side. There are a lot of dynamics in play."
Some observers took the HHS warning letter in stride, saying it was as much politics as policy in play. "With all the attention on the deficit, the letter let CMS show it's being tough on Medicare fraud," says Richard Temple, national practice director, IT strategy, at Beacon Partners, a consulting firm. "It was a dramatic flourish and not indicative of rampant fraud." Nonetheless, Temple offers one piece of advice to help sidestep any dubious billing.
"Use data analytics behind the scenes to analyze how frequently successive visits are duplicative or virtually duplicative of one another," he says. "That will allow you to proactively zero in. And then demonstrate to providers you have that kind of tool."
HHS FIRES A SHOT
Following is the full text of the letter HHS Secretary Kathleen Sebelius and Attorney General Eric Holder sent to five hospital associations warning them against using electronic health records to "game" the billing system. The letter was addressed 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:
"As leaders in the health care system, our nation's hospitals have been at the forefront of adopting electronic health records for use in coordinating care, improving quality, reducing paperwork, and eliminating duplicative tests. Over 55 percent of hospitals have already qualified for incentive payments authorized by Congress to encourage health care providers to adopt and meaningfully use this technology. Used appropriately, electronic health records have the potential to save money and save lives.