Upcoding: Is Your EHR Putting You at Risk?

Electronic health records are being blamed, in part, for the skyrocketing payments associated with level four and level five evaluation and management codes in private practices and hospital emergency departments. Over the last decade, the additional costs for E&M coding increases are estimated to be in the billions. 

In the last two weeks, The Center for Public Integrity and CMS have released several reports detailing how auto-coding, record cloning, and EHR software prompts make it easy to achieve inflated upper-level coding and additional payment for services. HHS and the DOJ have fired warning shots; the American Hospital Association has sent a rebuttal. More importantly, this war on coding fraud is not being fought in the Federal Register, but on the front pages of the newspapers like The New York Times, The Wall Street Journal, and The Washington Post.

What's at stake is a lot of money, and that attracts attention. According to federal regulators, just 1,700 of the 440,000 practicing physicians in the United States billed Medicare roughly $100 million in 2010 - most of them practicing in family medicine, internal medicine, and emergency medicine.

It's ironic that the technology physicians were incentivized to adopt, seems to be the root cause of runaway cost increases. But rather than debate the existence of EHR-generated upcoding, your practice should focus on what it can do to minimize the risk of audits and take backs; whether or not you use an EHR.

Here are six practical steps your practice can take to ensure that it is in compliance with Medicare standards, and lower its risk profile.

1. If your practice doesn't have a compliance plan - get one. Call your specialty society or use the version available on the OIG's website for small practices, assuming you are one. And, put teeth into it by actually doing chart reviews, whether you use paper or electronic systems.

2. If you are shopping for an EHR, be very wary of vendors who promise your patient encounters will come out at a higher level after you adopt their system.

3. Run a baseline CPT frequency report of your E&M services for each provider (sometimes called a productivity report) before you adopt an EHR. If you already have an EHR, running this report quarterly is a must. Look carefully at your practice's use of level 1 through level 5 codes for new patients, consults, established patients, and hospital visits for each provider.

4. Assess variations within your practice. Is there a logical explanation why Dr. Black's visits all seem to be level four, while her colleagues' codes are distributed across the coding spectrum?

5. Review the actual notes. Audit your practice records. Look for evidence of cloning or carrying forward notes on physical exams and patient histories. Better to find these yourself, rather than auditors. Make sure voice recognition-transcribed notes make sense. Our firm found this note during an audit: "Her thigh was swollen shunt." The physician actually meant to say: "His eye was swollen shut." Big difference!

6. Consider turning off the "auto-coder." As many coding experts have pointed out, physicians still need to use their brains. Remember, the nature of the presenting problem will be looked at in an audit - as uncomfortable as an ingrown toenail is, it hardly qualifies as a level 4 problem in terms of complexity and medical decision making.

Most of all - be proactive. There's little reason to doubt that the OIG will be looking at the connection between EHR-prompted coding and overbilling for patient services. Make sure your patient records accurately reflect physician services.

Karen Zupko is a seasoned senior advisor who has been helping physicians to navigate America's healthcare system since 1974. Her perspective stems from more than 25 years of consulting, coaching, and training experience with physicians and those who manage them. Zupko also teaches medical coding; serving as an instructor for the ACS, AAOS, AANS, and AAO-HNS. You can contact her at kzupko@karenzupko.com.