By Lisa A. Eramo
With just a few simple clicks of a mouse, physicians using an electronic health record (EHR) can create quite impressive notes filled with clinical information. The technology certainly saves time, but what effect, if any, does it have on compliant medical billing?
In its FY 2013 Work Plan, the Office of Inspector General (OIG) says that EHRs may have the potential to foster fraudulent practices that can yield inappropriate payments for evaluation and management (E/M) services.
Overly-templated documentation and/or the ability to quickly copy and paste information make it far too easy for physicians to unknowingly upcode (i.e., report higher-level evaluation and management [E/M] codes than what’s clinically justified), says Betsy Nicoletti, co-founder of Codapedia.com, a wiki devoted to physician reimbursement.
Data suggests that physicians have certainly been billing higher levels of evaluation and management (E/M) services over the last decade. In its May 2012 report, Coding Trends of Medicare Evaluation and Management Services, the OIG states that physicians increased their billing of higher level, more complex, and expensive E/M codes in all 15 visit types from 2001 to 2010. Approximately 1,700 physicians billed higher level, more complex and expensive E/M codes in 2010 at least 95% of the time.
However, are physicians intentionally coding higher levels of E/M services to obtain higher payments, or do these billing patterns simply reflect sicker patients or improved physician documentation?
The Department of Health and Human Services and the Department of Justice suggest that physicians may be using EHRs to intentionally engage in fraudulent practices. Both departments sent a letter dated September 24, 2012 to the American Hospital Association, three other hospital groups, and the Association of American Medical Colleges stating that there is evidence of providers who are “using this technology to game the system, possibly to obtain payments to which they are not entitled.”
Nicoletti says most physicians don’t knowingly engage in fraud. However, how can a physician be sure that his or her medical billing patterns don’t suggest such a trend?
Tip #1: Monitor your E/M codes. On a quarterly basis, compare your own data with that of CMS. Your specialty society may publish this information, or you may be able to obtain it from one of several publishers. Two examples include:
Your profile doesn’t need to match CMS norms exactly, but it also shouldn’t be a complete outlier, says Nicoletti. “A small variation is to be expected. Also, some specialists only bill level fours and fives,” she adds.
Tip #2: Work with your EMR vendor. Some EHRs suggest an E/M level, but physicians should only use this as a guide, says Nicoletti. Some practices may want to turn this functionality off entirely. “If you’re going to use it at all, someone needs to check the accuracy. An auditor needs to audit a percentage of notes before you turn it on and starting using it,” she says.
Tip #3: Use common sense. “If a patient comes in with a sore throat, and you document a comprehensive history or comprehensive exam, you don’t need to bill a higher-level code for that,” says Nicoletti. Take a few moments to review Appendix C in the CPT Manual, which includes specialty-specific clinical examples for E/M levels.
For more tips from Betsy Nicoletti, check out her upcoming webinar, Five Critical Activities to Prevent a Government Audit, which is coming up on May 16.
About the Author
Lisa A. Eramo (leramo@hotmail.com) is a freelance writer and editor based in Cranston, RI who specializes in healthcare regulatory topics, health information management, and medical coding.
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