Are EMRs Going To Generate Billing Audits?

Posted on November 28, 2012 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

As readers are likely to know, EMRs have already begun to get a bad rap among some payers — most prominently Medicare — as leading to upcoding and padding of services performed on the E/M side of medicine. It may seem a bit unfair for CMS to push for EMR adoption then waggle the finger of disapproval when they lead to billing changes, but that’s how the cookie crumbles.

The thing is, we’re not just talking about disapproval and public chastisements over billing patterns.  HHS has gone a step further than public tut-tutting. In the 2013 work plan for the HHS Office of the Inspector General, the OIG has specifically targeted EMR documentation for E&M services  as an area for study and possible audits:

We will determine the extent to which CMS made potentially inappropriate payments for E/M services in
2010 and the consistency of E/M medical review determinations. We will also review multiple E/M
services for the same providers and beneficiaries to identify electronic health records (EHR)
documentation practices associated with potentially improper payments. (emphasis mine)

According to Betsy Nicoletti, a prominent coding consultant who chatted with me this week about this topic, the OIG is going all out this year, looking at Medicare A, B, C, D and just about every type of provider you can imagine (such as, for example, skilled nursing facilities). Private payers are also getting particularly aggressive in looking for suspect billing patterns, particularly profiles that don’t fit with other physicians in a given specialty.

From what she told me, it’s not that EMRs are automatically suspect, but rather, that EMRs can create inconsistencies and red-flag billing patterns through the use of templates and forms.  For example, CMS may very well notice and audit your practice, she says, if the use of templates leads to using the same code too often (something CMS frowns upon, as it assumes patients’ conditions will vary widely).

If you want to get ahead of possible OIG audit problems, she suggests physicians read the work plan and self-audit in areas that are relevant to their medical practice.  Better safe than sorry, no?