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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 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?

Most Doctors Manually Code Despite EHR Automated Coding

Posted on July 17, 2012 I Written By

John Lynn is the Founder of the blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of and John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Pamela Lewis Dolan has a great article in AMA’s American Medical news about the automated E&M coding using an EHR versus manual E&M coding. Here’s a quote which sums up the article:

The Dept. of Health and Human Services Office of the National Coordinator for Health Information Technology asked the Office of the Inspector General to prepare a report looking at how Medicare physicians use EHRs to assign and document codes for E&M services. The report found that 57% of Medicare physicians use an EHR, and 90% of them use their systems to document E&M services. But most physicians still assign those codes manually, which could mean they are undercoding services that could qualify for a higher pay rate.

I’ve started seeing more and more people talk about this subject. It’s an amazing switch since one of the initial selling points of EHR software was this powerful E&M engine which would help them to ensure that they’re coding their office visits properly. In fact, many argued that with an EHR they were able to code at much higher levels than they could on paper.

In some ways, I think this can still the case if done right. The rationale is that many times a doctor would evaluate something on a patient, but not take the time to document it in the paper chart. Since they didn’t document it on the paper chart they couldn’t code for it. I’ve heard doctors say that thanks to quality EHR templates they’ve been able to document more of those “extra” items and so they can properly justify the higher code.

Obviously there are a lot of questions and risks associated with what I describe above. The most important being that many achieved the above result by using blanket templates which even included things that they never actually evaluated. There is a lot of talk about these blanket templates being a high risk during an audit.

Although, what I think the above quote highlights is something that I’ve seen regularly in healthcare. Many doctors are chronic under coders. I think this other quote from the article linked above explains why many doctors under code:

“If you do a cost-benefit analysis, it might be less expensive to undercode than try to deal with an investigation,” she said. But Fenton has found that there doesn’t have to be a large increase in coding levels to see a significant bump in revenue.

I’m sure there are many reasons that doctors under code, but this could be the largest one: fear. The fear of an audit uncovering over coding is real and palpable. Plus, an EHR automated E&M coding engine doesn’t solve this problem for a physician. At the end of the day the physician is still responsible for the coding, not the EHR software.