CMS-ONC Session to Address EHR Billing Controversy

Posted on by Frank J. Rosello

The controversy over the appropriate use of health information technology systems to streamline workflow while not fraudulently increasing healthcare claims will get a public airing early next month.

The CMS and the Office of the National Coordinator for Health Information Technology at HHS have scheduled a public, live and online “listening session” May 3 on “Billing and Coding with Electronic Health Records.”

The two federal agencies are convening the session with healthcare providers, health IT vendors, the news media and others “to discuss electronic health records (EHRs), the increase in code levels billed for some Medicare services, and appropriate coding in an increasingly electronic environment,” according to a CMS online posting.

Click here to view CMS online posting.

Speakers from government, hospital, physician, health information management, payer and IT vendor communities have been invited to discuss “the impact of EHRs on high quality clinical care, provider efficiency, and coding, as well as coding challenges and opportunities facing various groups, including hospitals, clinicians, and other interested stakeholders.”

Last fall, HHS Secretary Kathleen Sebelius and U.S. Attorney General Eric Holder issued a letter to various healthcare organizations warning them of suspicions that health IT systems were being used to improperly increase reimbursements.

The joint letter came in the wake of a report last summer by the Office of the Inspector General at HHS, indicating there had been an upward climb drift in evaluation and management coding levels in Medicare claims between 2001 and 2010.

EHR vendors have long hawked their wares by claiming their systems would increase provider revenue by enabling them to legitimately bill at higher E/M levels, and thereby receive higher reimbursements.

The assumption underlying the sales pitch was that providers were leaving money on the table by habitually undercoding patient encounters due to spotty or missing documentation—largely done on paper or not at all—a problem that EHRs supposedly would eliminate.

Another selling point for EHRs is that they can improve a physician’s workflow by automating repetitive tasks. Meanwhile, E/M variables include the extent of a patient’s physical examination conducted by a physician, or the taking of a patient history, which can be accelerated by use of computer functions, such as pre-loaded templates and “copy and paste.”

The inspector general’s office’s study period coincided with a time of gradual adoption of electronic health-record systems by hospitals through 2009, and then rapid adoption after that, according to federal data, as the effects kicked in from the EHR incentive payment program under the American Recovery and Reinvestment Act of 2009.

Also during the period, EHR adoption by office-based physicians increased, albeit at a more steady pace than hospitals and, so far, to lower levels of adoption than by hospitals.

Through February, the CMS and the states have paid out nearly $12.7 billion under ARRA-funded Medicare and Medicaid EHR incentive payment programs. Three out of four hospitals have received those payments, while 44% of physicians and other eligible professionals have been paid, according to the latest CMS report.

Sue Bowman, senior director of coding policy and compliance with the American Health Information Management Association, is one of the scheduled witnesses at the session. She’s scheduled to speak about developing standards for coding with EHRs.

In a telephone interview, Bowman called for the government to conduct some labor-intensive research, checking documentation and coding levels, “somebody digging in and really analyzing how much upcoding is going on” to get at the root cause of the higher coding levels noted by the inspector general.

Just because reimbursements are rising doesn’t mean it’s fraud.

“If you have an EHR, coding should be better,” Bowman said. “That’s one of the benefits of having an EHR, and if the coding does improve, that should lead to higher pay payment.”

Still, Bowman said, “there might be some feature build into the EHRs and it’s prompting you to higher level coding. You have to put controls in place to make sure they’re not being misused.”

“I think it’s better if it is not reimbursement-related,” Bowman said of the prompts. “Did you evaluate this system? Did you check this particular thing? But telling you in the prompt the reimbursement implications starts crossing the line a little bit.”

“Documentation should be about describing the clinical conditions of the patient and reimbursement should derive from an accurate account of patient care,” Bowman said.

Article written by Joseph Conn

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