Audit Risk: EHR Coding, Cloning, and Templated Notes

Audit Risk: EHR Coding, Cloning, and Templated NotesPhysicians beware: CMS recently expanded RAC audits (Recovery Audit Contractors) to include office visit (E&M) claims, with the goal of identifying inflated coding and aggressively pursuing fraud and abuse. A recent New York Times article, “Medicare Bills Rise as Records Turn Electronic”, alleged that “EHRs may be contributing to higher Medicare costs because they make it easier to bill more for services.” This is a natural outgrowth of the pre-meaningful use origins of many EHRs—they were typically designed to create a clinical note that would maximize reimbursement. The point-and-click, templated notes of many EHRs will also be subject to intense scrutiny—because the notes often include copied and pasted text and omit the nuanced information that is critical to truly meaningful documentation.

In a sternly worded letter to hospital and medical association executives on September 24, HHS Secretary Kathleen Sebelius and Attorney General Eric Holder warned that they “will not tolerate health care fraud” and will take steps “to ensure payment accuracy.” They expressed serious concerns that some providers are misusing EHRs to increase reimbursement by cloning medical record documentation and by upcoding visits.

This new focus on auditing E&M coding was spurred by the findings of a report by the OIG (Office of the Inspector General) issued in May 2012, “Coding Trends of Medicare Evaluation and Management Services.” Over the last 10 years, physicians have increased their billing of higher-level E&M codes and reduced their billing of lower-level codes. Therefore, the OIG recommended that CMS have its contractors review physicians’ billings for E&M services and that they review—for appropriate action—those physicians who bill higher-level codes.

One of Medicare’s administrative contractors, (National Government Services), recently announced that it will not accept cloned documentation. “Cloned documentation will be considered misrepresentation of the medical necessity requirement for coverage of services due to the lack of specific individual information for each unique patient. Identification of this type of documentation will lead to denial of services for lack of medical necessity and the recoupment of all overpayments.”

These audits pose a significant risk since auditors are paid based on the amount they recover from providers.

EHR Coding Dreams Shattered by the Evidence

The automated E&M coding feature of most EHRs has traditionally been highly valued by physicians in search of the Holy Grail. But, apparently this key EHR selling point is a myth! According to a report released by the Office of the Inspector General (OIG) of the Department of Health and Human Services (HHS), absolutely no one actually uses this highly touted feature.
EHR Coding Dreams Shattered by the Evidence
The survey concluded that physicians do not trust their EHRs to assign billing codes. Of the 2,000 physicians surveyed, 88% manually assign the codes for E&M services and the remaining 12% use professional billers to do so.

Perhaps the message has finally gotten out! As part of its 2012 work plan, OIG has specifically targeted billing fraud perpetuated by reliance on EHR coding/documentation. Physicians are scared. But the caution regarding automated coding should not come as news to anyone. It has long been known that EHR coding—along with templated notes—does not stand up well in an audit. An article in the well-regarded Medical Economics journal exposed these dangers several years ago.

Yet EHR sales reps continue to entice physicians by appealing to their desperate search for the Holy Grail of coding, offering an easy way to ensure that they will maximize reimbursement. I hope that the results of this study will redirect physicians to search for an EHR based instead on the potential to deliver improved practice productivity and efficiency and enhanced levels of patient care.