Published 11/1/2012
Karen Zupko; Mary LeGrand, RN, MA, CCS-P, CPC

EHRs Deliver on Promise of ‘Increasing Revenue’

But they also triggered a coding outcry at CMS

Karen Zupko and Mary LeGrand, RN, MA, CCS-P, CPC

Suddenly, it seems the popular press has developed an interest in medical coding. Perhaps it has something to do with money.

The details of how higher level evaluation and management (E/M) coding has cost the Centers for Medicare & Medicaid Services (CMS) “billions” hit the pages of The New York Times, Washington Post, and Wall Street Journal in September. The fuss was generated by a study conducted by the Center for Public Integrity, which indicated that Medicare spent $33.5 billion on E/M coding in 2010—an increase of 48 percent over 2001 levels.

The study, which echoed the results of an earlier investigation by the Office of Inspector General (OIG), also reported that the two highest E/M codes (levels 4 and 5) were on about 25 percent of physician-visit claims in 2001—and 40 percent of visit claims in 2010. Such an increase is sure to cause scrutiny by all payers—not just Medicare.

Several of the articles blamed the increases in levels 4 and 5 coding on the adoption of electronic health records (EHRs) in both the office and hospital settings. In fact, the Departments of Health and Human Services and Justice have singled out hospitals and emergency physicians for increased use of upper level codes.

EHRs—the very tool that CMS is paying practices to adopt—are now cited as a principle reason for the ballooning expenditures. Worse yet, the stories detail how the click of a mouse makes it easy for a physician to document that an exam was done, whether it was or not. Cloning visit notes, auto-coders, and cut-and-paste text were also mentioned as contributors to the overall increase in code levels.

There is no question that EHRs make it easier to document the work performed by physicians during patient encounters. This does not mean, however, that the higher codes are inappropriate. It is entirely possible that physicians were previously undercoding their patient encounters and that EHRs have corrected this.

Nevertheless, orthopaedic practices should pay close attention to these recent headlines and take appropriate action—particularly in light of the increased audit activity by Medicare Administrative Contractors (MACs) and Recovery Audit Contractors (RACs). The amounts of money in question are too significant to ignore, especially as the political debate about Medicare heats up. Ignoring these stories is like deciding to race through yellow lights—eventually, you will get hit.

The following steps will help orthopaedic practices reduce their risk and keep auditors of all types out of their records.

Implement or develop a compliance plan
Practices that have already developed a compliance plan should ensure that it is being followed—not collecting dust on a shelf. Well-run practices actually do what the plan calls for in terms of performing internal audits and making refunds. Practices that don’t have a plan should stop thinking about it, stop talking about it, and just do it.

Small groups will find the OIG compliance plan guidelines helpful. Larger groups should develop their plan in cooperation with an experienced healthcare attorney.

Review coding for ED services
In 2010, hospital billing for emergency department (ED) visits by Medicare beneficiaries were $1 billion higher than in 2006. That’s enough money to capture the attention of any Congressional representative.

Orthopaedic surgeons should examine their use of codes 99281 to 99285. Any claims filed with the ED as the place of service will certainly be scrutinized.

Conduct an internal audit
The Academy’s Orthopaedic Code-X software can be used to evaluate how an individual surgeon’s usage of level 4 and level 5 codes—whether for new or established office visits—compares against other orthopaedic surgeons on both a state and national level (
Fig. 1). The Code-X feature, E & M Analyzer, makes it easy to graph how a group or individual surgeon compares for each category and level of code. Simply entering the CPT frequency data from the practice’s billing system will generate full-color graphs, making trends easy to spot.

CMS has already announced that it will target level 5 codes for heightened review. In some regions, these codes are targeted for prepayment review. In other words, the documentation will be evaluated before the claim is paid, not after.

Orthopaedic surgeons should be aware that the RACs are on the case—whether they are qualified to conduct a proper audit or not. In a letter to CMS, the Medical Group Management Association makes the point “that RACs have not proven they have the skill and expertise” needed to review E/M coding. They go on to say that CMS data prove that “providers successfully appeal RAC audits 43.4 percent of the time.” Although this is a heartening fact, practices that get targeted by a RAC will face difficulty in filing and winning an appeal. Learn more about MAC and RAC audits and what the AAOS is doing in response at www.aaos.org/Medicare101

Assess documentation accuracy and compliance
Determining the accuracy and compliance of levels 4 and 5 coding is key to ensuring proper billing and payment. In a group practice, one partner can play “auditor” and review everyone’s notes. The “auditor” should focus on real issues—such as ‘cloning.’

When the documentation from visit to visit to visit is virtually identical, the note is considered to be cloned. This is due to the record’s being “brought forward” in the EHR from the last visit. The problem with cloned records is that the surgeon may forget to update the history (if the patient stopped smoking or actually lost weight) or do as thorough an exam as the previous visit note indicates.

To avoid some of the dangers of cloning, practices should not allow staff to autopopulate the review of systems and past family history into every note. In the old days of dictation, this would have occurred rarely, if at all. Doing it in the EHR leaves the practice open to the risk that the documentation is not accurate.

Assess the need for additional training
If the results of the previous action steps indicate that coding levels aren’t being selected properly, or documentation is not compliant, the appropriate staff and physicians should sign up for an upcoming AAOS coding and reimbursement course.

Assess the coding features of the EHR
One thing is certain—EHRs aren’t going away. But like any tool or technology, an EHR can be misused. In all of the popular press articles, EHR features such as coding calculators and documentation “helpers” were held responsible for the upcoding. They were also credited for helping improve documentation, reduce medication errors, and improve care.

Every practice needs to examine the various features of its EHR system to determine whether one or more could contribute to inaccurate coding. In addition, practices should assess whether everyone in the practice is using these features correctly. If physicians or staff need additional EHR training, it should be scheduled immediately.

Watch for action by other payers
Some surgeons think the code scrutiny will be limited to Federal programs. Wrong!

It’s not only CMS and their RACs who are interested. According to The New York Times, “higher coding has captured the attention of federal and state regulators and private insurers like Aetna and Cigna.” Private carriers have the same code usage data, the same increased payments, and the same concerns about upcoding.

Lastly, remember that practices that are audited for over coding will not be able to mount a successful defense using the following arguments:

  • “The EHR made me do it.”
  • “Who knew? The billing service did it.”
  • “Well, the girls who scribe must have made that mistake.”

As one government lawyer told physicians at a recent workshop on fraud prevention, “You are responsible for what is submitted on claims—pure and simple.”

Karen Zupko leads KarenZupko & Associates, Inc., a consulting firm that works with surgical practices on a wide variety of practice management, personnel, and reimbursement issues. She can be reached at kzupko@karenzupko.com

Mary LeGrand, RN, MA, CCS-P, CPC, is a consultant with KarenZupko & Associates, Inc., who focuses on coding and reimbursement issues in orthopaedic practices.

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