Stop penalizing doctors for effectively using EHRs

The health care crowd is abuzz with the New York Times revelation that Medicare billing rates seem to have increased by billions of dollars in parallel with increased adoption of EHR technologies for both hospitals and ambulatory services. The culprit for this unexpected increase is the measly E&M code.

Evaluation and Management (E&M) is the portion of a medical visit where the doctor listens to your description of the problem, takes a history of previous medical issues, inquires about relatives that suffered from various ailments, asks about social habits and circumstances, lets you describe your symptoms as they affect your various body parts, examines your persona and proceeds with diagnosing and treating the condition that brought you to his/her office or hospital. The more thorough this evaluation and management activity was, and the more complicated your problem is, and the more diagnostic tests are reviewed, and the more counseling the doctor gives you, the more money Medicare and all other insurers will pay your doctor. Makes perfect sense, doesn’t it?

In 1995 and again in 1997 Medicare has specified exactly how to measure a doctor’s thoroughness by creating 5 levels of visits and defining each level’s complexity in terms of an exact number of questions a doctor asks, and an exact number of organs and body parts that are addressed during a visit. The more sanctioned questions and body parts are addressed, the more money the doctor gets from the payer. During the olden paper days, no physician in his right mind would go to the trouble of actually writing down all these largely irrelevant things, and since Medicare always threatened to audit physician billings, most doctors practiced “defensive billing” and consistently charged less than they should have, because the hand written documentation was rarely indicative of the actual level of service. Enter Electronic Medical Records.

Since before the HITECH act and before the Meaningful Use epidemic, EHR vendors promised doctors an automated way of documenting a visit, so they can spend more time with the patient and not have to constantly write things down. Instead, a click on a couple of boxes would do that for them. Furthermore, physicians won’t have to waste money on expert coders to go through their scribbled notes and figure out a visit level. The software will automatically calculate the appropriate E&M code, based on boxes clicked. Structured data can be very useful for calculations. To make the entire process most efficient, three methods of documentation have been developed to replace hand writing and to efficiently minimize the need for extensive box-clicking.

  • Documentation by exception. Every EHR has this “feature” allowing the documenter to click on ONE box usually at the top of the page which generates a professional sounding clinical sentence for each organ or body part stating that everything is perfectly normal, or that all your histories are unremarkable in any way. This is a great efficiency to be applied presumably after the interviewer ascertained that all is well with your past and present relatives and body parts. If something is wrong with one or two organs, the clinician can click the Normal button and then edit the exceptional few organs that are affected today, thus obtaining documentation for a complete review or examination of all your systems. Remember that every organ and family member documented is worth a few more dollars according to Medicare’s fee-for-documentation model of reimbursement. No wonder then that this is now a basic feature in every EHR.
  • Pre-filled templates. These go by different names, but they are a huge time saver for simple and common problems and here is how they work: Let’s say you see a patient with an URI and it is flu season. You document the visit de novo starting from a blank URI template, use all the previously described efficiencies and generate a lovely visit note for this patient. It then dawns on you that you are likely to see hundreds of similar patients in the months to come, and that you always go about these things the same way asking the same questions and getting the same answers. You can save this visit note as a pre-filled template sans patient demographics and histories (really just the HPI, ROS, Exam and for the brave also Assessment and Plan) and when the next URI patient shows up, you can load this pre-filled template and edit exceptions, if any. Since technology is magical, EHRs will also load the patient specific histories and merge them into your brand new note automatically. Two or three clicks will get you enough documentation to allow your EHR to calculate a very nice E&M code and generate enough documentation to keep the payers at bay.
  • Bring forward. This is really sweet for complex patients with chronic disease that come to see you every few months or so. We all know that not much changes in a few months and most likely everything you will be documenting today is exactly what you documented six months ago. Instead of starting from scratch every time, EHRs have created great efficiency by making it possible for the documenter to bring forward, or load, the previous visit note and allow him/her to edit and make changes based on today’s visit. This beats the old “copy & paste” by a mile, and with a click of a button you have all the organs and relatives and complexity of decision making documented in minute detail. You can now make a few changes here and there as necessary, and the EHR will calculate the appropriate E&M code.

There are other features in most EHRs that are designed to improve reimbursement, but these are the most popular. There are also administrative functions embedded in larger EHRs that allow those who employ physicians to ensure that the docs click on all the necessary things to ensure optimal billing and payment. It is very easy to be critical of clinicians in these scenarios, but let’s remember that if Medicare wouldn’t have defined the value of a doctor visit to be proportional to the amount of text generated during the visit, none of this would have happened.

So the “unintended consequences” of pushing physicians to use EHRs seem to consist of doctors actually using EHRs, as effectively as possible, to document all the little details Medicare wants to see. This can only surprise people who had no clue what EHRs are, how they work, and how they are used in everyday practice, which did not (does not) prevent said people from proclaiming themselves as health care experts, best suited to set the national agenda for EHR design and adoption.

Margalit Gur-Arie is a partner at EHR pathway, LLC and Gross Technologies, Inc. She blogs at On Healthcare Technology.

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  • Dike Drummond MD

    Thanks for posting this … and this is a consequence of effective adoption of EHR that should have been plain as day.

    There is a whole industry within healthcare focused on helping doctors with their habit of chronically UNDER-charging for patient visits. These consultants come in and teach you how to document and code to maximize your billings … a natural desire in a FFS environment. This has been going on for decades. Some organizations even take choosing the visit code for the visit out of the hands of the physician – because of our chronic tendency to undercharge.

    Enter the EMR and assume it is used with some thoroughness and skill. Voila .. the billing process is automated. The EMR can figure the charge without physician input. BOOM … there should be a step-like increase in billings. That should have been anticipated. AND it has nothing to do with doctors changing what they do at the point of care.

    If anything … this represents what is actually happening at ground level in a snapshot that reflects reality for the first time.

    Dike Drummond MD

    • Margalit Gur-Arie

      Hi Dr. D, very good points. I would like to add another.

      All these numbers being published now are ignoring another interesting development occurring in parallel with EHR adoption.
      Practice management and billing systems are much better than they used to be. Most have multiple levels of checks and balances and scrubbers, all intended to “fix” the claims before they reach the payer, and insure that all rules and regulations, such as medical necessity, are met. This causes higher “first pass” success, less denials and less write offs, and therefore higher reimbursements. And just like appropriate coding in (by) the EHR helped physicians and hospitals obtain fair payments, within this crazy system, so do the new revenue cycle management systems. Computers are good at numbers.
      So instead of screaming fraud, most payers should just accept that they are being beaten at their own pathetic game right now.

    • Laurie Morgan

      Agree completely — it is rare for us to work with a practice that does not have some level of under-coding (defensively, fearfully) that hurts their bottom line significantly. EMR has the potential to help make it easier for doctors to systematically bill fairly and properly.

  • LeoHolmMD

    Good shot. Medicare caused this problem…now they can eat it. Thats what they get for shoving EMR down everyones throats and paying doctors to click bubbles all day instead of actually treating patients. If the clowns at CMS would just bang their heads hard enough against the cost curve, it might start going down.

  • southerndoc1

    “people who had no clue what EHRs are, how they work, and how they are used in everyday practice, which did not (does not) prevent said people from proclaiming themselves as health care experts, best suited to set the national agenda for EHR design and adoption”

  • Margalit Gur-Arie

    Speaking of payments, or lack thereof, AHA and and a bunch of hospitals (one in my backyard) just filed suit against Medicare and its RAC auditing policies of questioning where care should have been provided.


  • Thrive Boston

    I work in mental healthcare, and while my practice can afford it, the biggest limitation with EHR that many small practices in my sector suffer is that they can’t afford a decent EHR system, and won’t receive any financial incentives for their use.

  • Richard Rosol

    Fantastic assessment of the many EHR problems. For me, the most insidious danger is the tyranny of the template. In my practice, doctors all around me greeted templates with open arms. How great is it to have that URI template locked and loaded before the doctor even enters the room! Great, if you don’t mind the rooming RN (or MA!) making the diagnosis for you. Since when is diagnosis the FIRST step? Even if the doctor is the one who invokes the template, to be of any use it still has to be done before it’s appropriate to diagnose the condition.

    Another serious problem, in my view, is the use of ICD codes in lieu of diagnoses. ICD codes are for payers, who care little how medically descriptive the verbiage is. If diagnoses have to be grouped, batched, dumbed down for payers, I’m okay with that. Whatever you need to do to get paid, fine with me. But those codes and descriptors DO NOT WORK in the other direction and do not belong in the patient’s medical record. And how many times have I been hamstrung by our EHR to properly code the visit before I could make a plan, order appropriate tests, or prescribe?

    All concessions made for the sake of convenience. And the conveniences don’t even save me time! WTF?

  • ClinicalPosters

    EHR has had other consequences. Physicians I’ve encountered over the past five years appear more focused on their computer screen than the patient. They rattle off a few odd questions while keyboarding like, “No unexplained weight loss?” at a time when I clearly gained weight since my last visit and, “No blood in the urine?” to which I respond, how would I know that? It appears as though the patient consult is guided by checkboxes.

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