Certifying EHR: Ways to Move Forward

Kathy McCoy, MBA September 6th, 2012

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OIG found practices that were consistently submitting claims for higher-than-typical levels of E&M care also recently implemented EHR systems

This is part II in a series about an ongoing Office of Inspector General (OIG) investigation concerned with miscoded Medicare evaluation and management billing. In the first part, we introduced the problem and posed questions about related issues. Although resolution may be far off, as the OIG investigations continue, we think it may be reasonable to consider the steps ahead.

Investigation Background

Between 2001 and 2010, OIG auditors investigated thousands of physicians and their practices to determine why Medicare evaluation and management (E&M) billing seemed to be migrating into more expensive and more complex medical billing codes. OIG found 1,700 physicians and practices that were consistently submitting claims for higher-than-typical levels of E&M care. They also found that these same physicians and practices had also recently implemented electronic health records (EHR) systems. While it is important to remember that investigations are ongoing and no conclusions have been reached, it is becoming clear that there is a lot of work to do to make EHR products compliant with Medicare E&M documentation requirements.

If we were able to submit a “wish list” of industry and product changes, that list would include some or all of the following:

  1. Set Higher and More Consistent Standards — EHR vendors and the products they market must rise to meet a much higher standard of compliance for certification. Among the many changes required are significant design and function enhancements, audit protection for users, a capability to determine medical necessity and protection against over- and undercoding. Products that meet these CMS compliance standards should be certified as Medicare-compliant, and such certification should offer a degree of protection to users from investigation.
  2. Teach Compliance– Medical schools should use and teach on E&M documentation-compliant software. Physicians should be trained in the use of software that will facilitate efficient recording of relevant data and at the same time support compliant documentation requirements of Medicare E&M.
  3. CMS to Lead the Way – While CMS provides standards of compliance for others to follow, it must meet its own standards as it oversees the design, production and implementation of software vendors’ EHR products. CMS can integrate its compliance standards requirements into its existing EHR adoption incentives to encourage the use of compliant documentation products and at the same time prevent non-compliant designs from reaching the market.
  4. Shift the Focus from Physicians to EHR Software Vendors – The software engines that drive collection of E&M data are surprisingly consistent from product to product. OIG should refocus its enforcement attention on EHR vendors and those products that produce non-compliant E&M documentation. We would like to see CMS build audit protection into its certification standards so that products marketed to physicians can actually protect them from submitting flawed E&M documentation.

What is the big takeaway? It looks like physicians who have begrudgingly tolerated systems that forced them to simplify their E&M data collection into canned scripts and templates have been unfairly targeted. Yes, compliant documentation is ultimately the responsibility of the entity submitting the data, but until the smoking gun behind the miscoded E&M billing is located, we believe leniency is in order.

Read Part I of this series now.

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