With a greater emphasis on
electronic medical records (EMR), more and more physicians and health care
providers are relying on the EMR to perform their coding for them.
It may seem
an obvious choice for providers who have made a substantial investment in technology
and hope to recoup some of that by having that technology code for their
practices however greater use has resulted in some disturbing findings when it
comes to coding through the EMR.
What you need to consider...
Planning for and
implementing and EMR should take between 6 to 12 months. After that full
implementation can take another 12 to 18 months. EMR vendors want to make a
sale, and they often under-estimate the planning and training that any one
specific practice needs.
Without planning and implementation specific to YOUR practice and your
specialty, your practice may be relying on standard templates, or templates
that were hastily set-up and not appropriately tested against a “real live
Studies have shown that when
an EMR system’s documentation features are improperly used, you actually increase
your risk of an audit.
The risks of audit increase due to systems that are set-up with “cut and paste”
options for documentation, systems that automatically assign a “negative
finding” to and ROS, PFSH or HPI box that is not completed, and of course
systems that auto-fill any areas of the template.
According to an article in Part B News,
the “proliferation” of EMR systems “allows easier documentation,” thereby justifying
higher E/M levels. It is likely Medicare may target these code levels for an
audit sooner rather than later.
Many vendors will claim that the EMR will ‘code’ for you.
They may also infer or even outright claim that EMR coding will help your
practice make more money. Remember…”If it sounds too good to be true, it
sure that you and your practice colleagues understand the logic behind your EMR’s
code calculator. Often the algorithm for the medical decision-making (MDM) component
of the E & M coder is simply incorrect, resulting in suggested code levels
that don’t match the documentation and can put your practice at risk.
out your specific specialty practice management journals. In each one, you will
find reports of practices who have found that their high level E & M codes
increased after implementation of their EMR.
In some cases, this shift in the
standard bell curve has resulted in insurance audits with findings showing that
the codes were too high for the documentation in the EMR. In other cases, practices
have been more pro-active in light of these E & M code “improvements” and
they decided on an audit in which the inaccuracies were confirmed, allowing the
practice to have their billers override the suggested code(s) and bill the
OIG 2012 Work Plan Includes Review of EMR/EHR
The 2012 US OIG Work Plan includes
direction to review EMR/EHR systems due to concerns over system up code
selection, cloning of patient data on subsequent visits, and auto population or
“auto fill” features. Audits have shown electronic charts with data pulled
forward without updates by the physician, histories auto populated without
evidence the work was actually performed and charts where EMR/EHR systems have
up coded based on history and exam elements without the proper medical necessity.
99214 is currently the most audited code due to this systematic up coding.