Overcoding vs. Proper Coding

During a speech at last weeks Federation of American hospitals conference, acting CMS administrator Marilyn Tavenner discussed the CMS concern about the practice of upcoding, in which providers consistently code at a higher level of service than justified by the service actually provided. It has been argued that EHR usage makes this activity easier, because providers can copy old data from notes and document alarge amount of the physical exam with a single click. Many EHRs have a function that can keep track of what was documented within a single visit and calculate the appropriate billing level. CMS and others are concerned that EHR’s are partly responsible for a dramatic increase in the number of higher-level visits being billed by providers. Between 2001 and 2008, hospitals increased billing by about a billion dollars for emergency room visits. A similar increase has been seen with billing of outpatient office care. CMS has announced that they will be instructing healthcare organizations about Electronic Health Records and conducting small, targeted audits to ensure electronic billing is done properly.

But is the CMS concern entirely warranted? The advantage to an EHR is that the documentation is clearer than the potentially illegible handwritten note, making it easier for coders and providers to quickly review what they’ve covered and realize that they can bill for a higher level of services. With paper records, if a provider wanted to safely bill at a higher level, they needed to ensure that all the proper documentation (often repetition from a previous visit) was re-documented. Often this leads a provider to simply consider billing at a slightly lower level, given the time commitment needed to fully document a visit from a very complex patient. With EHR’s, however, not only are some systems built with technology capable of capturing and measuring an estimated billing level, but the ability to quickly import past histories and document that a system was reviewed without major changes enables a provider with a very complex patient worthy of a higher level of service to document that service without spending an overly excessive amount of time doing so.

At the same time, some providers are undoubtedly using these advantages to code at a higher level than is appropriate. The ability to clone an old note means that a less honest provider could simply assume that a patient in for one problem is fine in every other system and document a full review without actually spending the time doing so.  There is likely a mix. Many providers have used the advantages of an EHR to move billing to an appropriate level of service. Others, however, have taken this a step too far and taken even the simple visits a level up, expecting that nobody will notice. But this is exactly how payers identify practices worth auditing. If a doctor codes frequently enough at a level outside the normal range of distribution, that is the sort of activity that will draw the attention of payers to investigate further. If EHR usage is bringing coding to an appropriate level and reducing under coding, this activity should hold true through all providers, forming a sort of bell curve.

An EHR is never responsible for fraudulent billing. The provider is ultimately responsible for an accurate assessment of the level of service provided. In this regard, it is important to remember that detail of documentation is only one factor that is considered in evaluating the level of service. Severity and complexity of the problem(s) addressed at the visit is also critical.  Providers should look to EHR’s to facilitate documentation and improve patient care, but not primarily to allow them to increase level of service.

Further Readings:

CMS Audit Program Guidelines

AAFP: Data Show Upward Trend in Medicare CPT Codes Key to Primary Care

Dallas/Fort Worth Healthcare Daily: Cracking Down on Overcoding and Upcoding in the ED


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