Physicians, Practices and EHR Under Scrutiny by OIG

Kathy McCoy, MBA August 30th, 2012

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OIG investigations are continuing and no conclusions have been drawn, but it is clear that the practices and facilities that have been found in error are using EHR systems.

“Greater use of electronic medical records (EMRs) has the potential to improve the quality of medical care and has become a goal of the U.S. administration,” according to a 2005 report by Catherine W. Burt and Jane E. Sisk of HealthAffairs.org. As adoption of EHR has continued since the mid-2000s, few have argued that point.

Until now.

Investigations, Suspicion and Fraud

In recent investigations, the Office of Inspector General (OIG) has found that since 2001, 1,700 practices and facilities that perform Medicare evaluation and management (E&M) are shifting their E&M codes from 99211, 99212 and 99213 codes to the more complex and more expensive 99214 and 99215 codes. OIG investigations are continuing and no conclusions have been drawn, but it is clear that the practices and facilities that have been found in error are using EHR systems. As the news ripples throughout the industry, many suspect that the miscoding is due to EHR systems that are not equal to the task.

CMS is incentivizing adoption of EHR, with the final Stage 2 Meaningful Use rule just issued last week, and will also penalize practices that fail to adopt the new technologies. Healthcare Reform legislation has made adoption of EHR systems a centerpiece, and the Administration believes that these systems can even effect an improvement in the economy.

Encourage, Promote and Flee

Yet the very systems that have been encouraged, promoted and incentivized, may be the source of tremendous amounts of miscoded billing. That these automated systems are under suspicion–and not inattentive billers entering codes manually–offers no comfort to physicians and practices that are being audited, investigated and fined.

How did this happen?

While EHR vendors boast of their systems’ data storage and retrieval features, their products seldom facilitate the physician’s individual work style. Instead, physicians find themselves conforming to templates and scripts that fail to require–or have no room for–the very E&M information they’ve spent their careers recording diligently by hand. The absence of data is, in effect, bad data, and when an office visit is reduced to a simplified, canned set of questions, information can be lost. Correctly coded billing is dependent on plentiful and accurate data, and without it, miscoding occurs.

Too Many Promises

With investigations underway, some physicians and healthcare organizations that have dutifully complied with implementation of these systems feel they have been oversold. They’ve been promised that EHR systems and processes would enhance their operations, and for their efforts they have become exposed to audits and fines.

Adding to the pain, EHR systems’ vendors typically require their customers to agree to contracts that disavow the vendor of responsibility for coding compliance and its proper documentation. Even though these systems produce non-compliant E&M documents when used exactly as specified by the product’s designers, vendors are absolved of their legal responsibilities. The consequences for these errors rest entirely on the shoulders of the customer.

It’s Far From Over

With CMS so deeply involved in the implementation of HIT, one might wonder how it can be absolved of responsibility. Isn’t it CMS’ role to ensure that HIT vendors provide products that are compliant and produce accurate documentation? Yet HHS’ Office of the National Coordinator has not established standards for how physicians should use EHR systems to create medical records that meet CMS documentation requirements for E&M services. 

Resolution of this issue is not yet in sight. ONC officials want more information regarding physicians’ implementation of EHR systems, and will be studying exactly which EHR systems the Medicare physicians under investigation were using. For more information see Modern Medicine’s The Problem with EHR and Coding, and watch this blog for Part II, Certified EHR: Suggested Ways to Move Forward.

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