Electronic health record (EHR) software applications feature tools that assist providers with improved charge capture and more accurate evaluation and management (E&M) coding. These systems record the type of visit and the relevant information documented in the history, physical examination, assessment, plan, and other sections of the clinical record. When a procedure is selected, the supporting billing codes (e.g., ICD-9-CM, HCPCS, and CPT©) are recorded and made available to a practice management system, greatly reducing the potential for the provider to neglect to enter this code on a paper super bill. The systems also automate the calculation of a suggested E&M code that is then presented to the provider for review and approval. In general, improved charge capture leads to somewhat higher coding levels, with annual per provider reimbursements increasing in some cases by $30,000 or more. Currently less than 20% of physicians are using EHRs, but as this number increases, payers are likely to see an increase in average physician billing levels. This in turn may prompt more rigorous assessments of how providers are using EHRs and their E&M coding tools.

This article will explore how EHR coding tools, if used correctly, can improve charge capture and the accuracy of E&M coding. It will also examine how some features unique to EHR documentation and E&M code determination, if improperly used, could put providers at risk for submitting inaccurate codes or even committing fraud.

EHRs provide a great deal of structure to the documentation process by presenting context-specific information that can be used for optimal clinical care, guideline compliance, medicolegal defense, and accurate coding. EHRs recognize charges that should be captured during clinical care and when information related to evaluation and management coding is documented in the history, physical examination, assessment, and plan. However, these coding tools are not perfect and require the user to carefully review the documentation and codes presented before authorizing it to be submitted for the specified encounter. A significant benefit of this process is that feedback on coding rules presented to the provider during the documentation process can improve provider understanding of E&M coding and improve their coding accuracy. Users must also carefully screen for charges that may have been generated through the EHR but that were not actually provided.

Providers need to be aware of certain nuances of EHRs that could lead to inaccurate documentation and coding. Several examples are detailed below:

Templated documentation EHR products typically use some type of stored text in the form of templates or macros to improve documentation efficiency. This may include procedures that are checked by default (e.g., ordering a urinalysis when using a template for a urinary tract infection). Templates may contain extensive levels of detail for each section of the note that are “pre-populated” with information that may or may not be accurate for the visit at hand. On the positive side, templates can improve care by increasing compliance with quality of care measures and by providing clinicians with information related to history taking, the examination, diagnosis and management, and compliance with guidelines. However, templated information represents defaults that need to be carefully modified and reviewed by providers. Templated defaults in the review of systems (ROS) section of a note are a common example of information that may contain a number of default values (e.g., denies fever, chills, chest pain, cough, etc.). Accepting defaults that do not precisely match the information that was obtained during the encounter may be considered fraud, particularly if the default information is used to support the E&M code submitted via a claim or reflects procedures that were not actually performed during that encounter.

Pulling forward information from previous notes Many EHRs allow providers to reuse some or all components of an old progress note as a template for a new visit. This can improve the efficiency of documentation. But information that is pulled forward must be modified so that it accurately represents the information that was obtained during that visit. This process may also lead to orders being automatically pulled forward from a previous encounter that were not indicated during the current visit. Using information that was not actually obtained during the visit to justify an E&M code or billing for a procedure that was not actually performed, may also be considered fraudulent behavior.

Automated settings that lead to documentation that is not medically necessary from a coding perspective This may occur when the EHR has automated settings that add, for example, the patient’s social and family history to each visit, even for frequent minor visits (e.g., blood pressure checks). For some encounters, this may not be medically necessary and should not be used in the calculation of the level of service for that visit.

Documentation of complexity of medical decision making in the assessment Detailed discussions related to the thought process surrounding how diagnoses are rendered are often unique to each clinical situation. This type of information is difficult to capture via templates or macros, making this an area that may require additional effort on the part of providers. EHR products vary significantly in how they manage the documentation in this section. In general providers should avoid bulleted lists of diagnoses without supporting documentation.

Another concern is that the approaches taken by different EHR vendors vary considerably as to how they calculate the suggested E&M code and how information on what charges are being forwarded to a billing application or service is presented. The nuances of calculating the complexity of medical decision making, which include number of diagnoses or management options considered, amount and/or complexity of data to be reviewed, and risk of significant complications, morbidity and/or mortality, often require some degree of direct input from a provider. Some EHR vendors walk a fine line when their tools encourage users to add additional documentation to support higher levels of coding; a process that is viewed by many coding professionals as encouragement for providers to add documentation that may not be medically necessary solely for the purpose of increasing reimbursement.

In summary, the use of E&M coding tools in EHRs has the potential to improve charge capture and the accuracy of coding, although this generally leads to higher coding levels per encounter. This will in turn lead to greater scrutiny of how the coding related aspects of EHRs are used by providers, who remain responsible for the accuracy of the codes they submit via claims.

Providers will need to carefully review the generated claims from each encounter and expand their knowledge of the E&M coding rules. EHR users are encouraged to participate in continuing education specifically related to how their EHR calculates E&M codes and how to avoid committing what might be viewed as fraudulent behavior. A key component of this should include the need to remain vigilant in ensuring that any machine generated documentation contains information that was actually performed, medically necessary, and free of any material (e.g., template defaulted findings) that does not accurately reflect procedures performed or findings obtained during the visit. Lastly, given the variances between EHR systems, a federally recognized certification process for EHR E&M coding tools would help to standardize the process by which the E&M coding levels are determined in EHRs. However, even with this tool in place, providers will still need to have a detailed understanding of the benefits and pitfalls of using EHRs from a coding perspective.

Reprinted with permission from Parses, Inc

President and CEO of e-MDs Dr. Stearns is a board certified neurologist and one of the more experienced physician health care informaticists in the nation. e-MDs Solution is a Texas-based electronic health record and practice management software company. Dr. Stearns is a member of the ASHIM’s Health IT Industry Advisory Panel, the Health Information Technology Standards Panel, and the AAPC’s Family Practice Steering Committee.