Using the F-word when it comes to EHRs

Not long ago, Secretary of Health and Human Services Sibelius and US Attorney General Holder issued a stern warning to healthcare providers who are using electronic health records (EHRs).  The federal officers maintain there has been an alarming increase in the charges to Medicare in institutions where EHRs have been implemented, and they warn that those behaviors will be treated as “fraud,” an illegal gaming of the system to increase reimbursement to those institutions and their physicians.

Let’s revisit billing for healthcare services.

Charges for healthcare services are submitted on “universal” billing forms, which utilized both alphabetic entries (e.g. the patient’s name) and numerical entries (practically everything else).  There is a lot of information on a billing form, but the meat of it is the list of diagnostic and treatment codes, which are standard numbers assigned by the International Classification of Diseases (ICD) and Current Procedural Terminology (CPT).  Those codes determine how much the institution and the physician will be paid.

In the traditional chart, physicians entered diagnoses and treatments using handwritten words.  In order for those words to be used for billing Medicare or any other payer, they had to be converted to the numbers assigned to them by ICD/CPT.  That conversion was accomplished by “coders”, people trained in the terminology of ICD/CPT, but not necessarily or usually in a clinical discipline.

It is important to understand two things here.  The first is that, although ICD/CPT are creations of organized medicine, the terminology within them and that employed by doctors on a day-to-day basis can differ significantly.  The second is that most doctors have ordinarily regarded “charting” to be a low priority task, one that is to be accomplished as rapidly as possible so that the  next patient can be seen, the next task initiated.  The upshot is that doctors have developed a system of taciturn entries employing abbreviations, acronyms, and symbols to get their message across in the shortest possible time.

One of the most extreme routine progress note entries was that employed by the chief resident in neurosurgery, when I was an intern on his service.  For most of his patients, throughout sometimes prolonged hospitalizations, the progress note each day would be “ᶲΔ”, “phi” being the mathematical symbol for “null”, “delta” the scientific symbol for “change”, therefore “no change”.

The neurosurgeon’s note was egregious.  Most physician progress notes actually contain valuable information, but when it is expressed in symbols, etc., that may be perfectly understood by doctors, it is not information that can be coded.  The diagnoses therein do not contribute to the severity of illness or services, therefore, and Medicare and insurors benefit from a non-contractual but nevertheless substantial discount.

Before the Affordable Care Act (ACA, ObamaCare), there was the American Recovery and Reinvestment Act of 2009 (ARRA).  ARRA mandated the utilization of EHRs and reinforced that mandate with a series of financial consequences for providers that progress with time from positive (bonuses) to negative (penalties).

There are dozens of EHR products on the market, and I have seen a relative few.  All those however, and I suspect those I have not seen, incorporate standard terminology that corresponds to ICD/CPT.  Now the doctor, without sacrificing time-efficiency, can incorporate fully informative entries into the chart that will satisfy the criteria by which the coders are bound, and the result will be a universal billing form that more accurately describes what was wrong with the patient and what the institution and doctor did for him or her.

The charges to Medicare will be increased thereby.

The Secretary and AG allege that providers are “cloning” EHRs, somehow documenting services that were not actually provided.  If so, that deserves the “f-word” and all the legal consequences that go with it.  I think any such behavior represents a vanishingly small fraction of the increase in charges they have observed, though.  I think they are seeing the consequences of ARRA EHR mandate, and I believe they will see more and more as EHRs become more widely utilized.

This is a completely predictable outcome.  One of the attributes touted for EHRs is the standardization and completeness of the medical record, creating one that can be shared by multiple users and be meaningful for all.

I am confident that HHS/Medicare and the insurance companies will find ways to neutralize the resulting increases in charges.

Richard Patterson is a surgeon who blogs at DailyDudley.

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  • Robert Young

    Great explanaton of billing codes, which by the way will increase 10 fold shortly as ICD-10 replace the current ICD-9 codes. Won’t that be fun! And ICD-11 codes will replace these in a few years which have been used globally for many years n those countries where costs are half our’s and care statistics are much better.
    As 30 to 50 million new, low paying Medicaid recipients from ObamaCare being brought into that entitlement program, while 4 million “boomers” come into Medicare each year for the next 10 years; while the population of physicians and nurses are in short supply, which entitlement progrm members will come up short and how will care be rationed as consumers increase by 25%?
    Only those government computers will tell!

  • John Henry

    Now that CMS is being charged for the work actually done, as EHRs are able to completely document, the codes are resulting in accurate billing, not fraud. If anything, the CMS and insurers have lost their scam that allowed them to underpay doctors who undercoded for fear that an audit would uncover some deficiency in documentation resulting in accusations of overcoding, and fraud.

    Now this term “cloning,” which is a pejorative used by the CMS administrators that includes similar documentation when serial similar findings are made–something that is neither fraud, nor untruthful, nor any kind of proof that the work documented was not done–is being used to suggest that the documentation is fraudulent because it documents similarly. It is a totally dishonest and illogical allegation that completely lacks any proof to its veracity. The officials who suggest there is fraud should be called out for this; identical notes for identical findings are not a finding of fraud.

    • Myra Reed, MD

      Excellent response! So truthful. We are definitely not over coding or billing. In fact, we are under paid and over worked along with more cuts coming soon. Implementing EHR has been not only extremely exhausting and time consuming , but also very expensive. I am on my third EHR which means three times the expense due to buying and loosing significant money on software, support, training, lots of new hardware , IT help constantly needed which is very expensive, overtime pay to employees along with adding extra employees to my staff, having to retrain new and current or previous ones, seeing less a patients since it takes so long to put information only important for government data not to patient care, loosing patients because they have to wait longer to be seen, and figure out the right codes and modifiers in order to pay an expensive biller to send it through a paid clearing house then finally to the insurance company only to be denied for whatever reason or for no reason at all except they have to deny a certain percent across the board, just because! Then I have to pay to resubmit! Just to name a few!
      Tell me where the fraud is?! Not on the doctors side for me.
      I am a primary care internist pushing harder to make a living. Primary care physicians that we know today are quickly becoming an entity of he past. We are forced out of having the finances or strength to continue. The government has taken over forcefully. I make the analogy to my patients of how the Jews felt just over 50 years ago. Health care is already on the train headed to a sad, dark place. Believe it or not , I am always an optimist. But facts are facts. Socialized medicine is here with Obama Care. The train is running down the track full speed to an unknown scary place. How can anyone say fraud or over billing? We are being punished for working hard and caring for people. The real fraud comes from attorneys and government waste and their self expense. Why not cut their pay especially after they leave office!

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