Overcoding vs. Proper Coding

Posted in HIT on March 13, 2013 by Matthew Levy

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

Thoughts on the Cost of EHR Implementation

Posted in HIT on March 8, 2013 by Matthew Levy

There are many healthcare-changing initiatives being talked up these days. These include promotion of technology through HITECH and changing the way medical doctors code for problems through ICD-10. In selling these efforts to hospitals and providers, the people responsible will couch their arguments in benefits to the providers and the patients: EHR’s are supposed to make keeping track of patients records more efficient and enhance quality initiatives, e-prescribing is beneficial because it allows for automated interaction checks, ICD-10 allows description of medical conditions and procedures to be more thorough.

In the latest issue of Health Affairs, there is a study from Julia Adler-Milstein, Carol E. Green, and David W. Bates that explores the effect that implementing a new EHR has on profits for medical offices and practices. In “A Survey Analysis Suggests Electronic Health Records Will Yield Revenue Gains For Some Practices And Losses For Many” the authors reveal a mixed result that in theory (and in the title of the article) seems to confirm some of the worst assumptions about EHR use that physicians may hold.

But EHR implementation, despite the way it is presented in Health Affairs, is not meant to increase profits to hospitals and providers. It is primarily about improving quality of care and office efficiency. This is not to imply money plays no role in the process. Healthcare is, after all, a business. But the changes to the system have not been designed with increasing profits as a primary goal.

The amount of money being spent as part of Medicare and Medicaid has skyrocketed as healthcare has gotten better at keeping people alive and treatments have gotten more complicated. All payers, both private and public, are looking for ways to reduce payments, which has providers and hospitals left scrambling for ways to control their own costs. The Centers for Medicare and Medicaid Services (CMS), which oversees the Meaningful Use attestation program, is pushing ICD-10 implementation for various reasons, but admits that the primary goal is enabling it to have greater data on what treatments providers are billing.

We have always been aware of the costs to effectively implement EHR’s. This is why Meaningful Use incentives exist. Essentially, CMS believes that it will do better in the long run if providers keep and use electronic records and is willing to pay providers, after the fact, if they make that change.  The other problematic element within the study is that EHR implementation isn’t just failing to result in a profit, but that in practices with fewer than 6 providers, money loss is occurring. In essence, the cost to implement the new technology is not outstripped by gains in productivity over the long haul.  The study noted possible reasons for this. Almost half of offices were still maintaining paper records. Others will still maintaining and paying for staff to handle tasks that were rendered obsolete by new technologies, including transcriptionists and staff to maintain the aforementioned paper records. On the other hand, some practices increased efficiency and were able to see more patients; others improved billing and had fewer rejected claims. Larger practices (with more than 5 providers) were more likely to recoup costs than smaller ones.

This study was not designed to look at improvements in patient care, but does confirm that some, but not all, practices may benefit financially from the adoption of EHR’s, especially larger practices and those that use the change to improve efficiency in their offices. The final result of the article, despite a misleading title, is to point out a few important things. Practices who commit fully to using an EHR can see more effective billing practices leading to higher coding levels and fewer rejected claims. On the other side, those groups not interested in breaking from the past will end up wasting most of these potential advantages. In our experience, commitment to a successful implementation process should lead practices to not only improve their business model, but do a better job with their original mission: helping their patients.



HIT Learning Center Webinars

Posted in HIT, Learning Center with tags , , , , , , , , , , , , , , , on March 7, 2013 by Matthew Levy


As part EHR Evolution’s upcoming HIT Learning Center, we are offering FREE Webinars explaining the changes to the healthcare system as part of the HITECH act. Whether you are a provider, administrator, IT professional, or have any other role in healthcare, you can join us to learn more about some of the requirements for Meaningful Use Stage 2. Additionally, we will begin to show you some tips for making this change as painless as possible.

Join us throughout March to learn more about how EHR Evolution can help you transition to a more effective computer-based system for managing your practice.

To sign up, click on one of the links below.


ICD-10 Implementation

Posted in HIT on March 6, 2013 by mfisher527

We have discussed at length many of the changes to healthcare practice and policy that are currently being proposed or implemented. Most of these are driven by new advantages in technology that allows us to take advantage of new technologies to improve the way we treat and interact with patients.

Currently ICD-9 (International Statistical Classifications of Diseases) codes are in place to report medical diagnoses and inpatient procedures.  Several chapters in ICD-9 are full and new codes can not be added. The practice of medicine has changed dramatically in the last couple of decades. The years since ICD-9 was implemented in 1977 have seen new conditions and diseases discovered, new treatments developed, and dramatic changes in medical devices and resource roll outs. As a result, new problems, conditions, and updates and expansions of known medical issues cannot be separated as we discover new medical knowledge. This severely limits billing and treatment options.  ICD-9 can not keep up with all these advances and changes in the system are inevitable. ICD-10 is rolling out and will replace ICD-9 on October 1, 2013, the compliance date is October 1, 2014.

What is the difference between ICD-9 and ICD-10? ICD-10 provides more  specific and in-depth diagnosis codes and procedures. The new set of codes will describe precisely what procedure was done to the patient, what body part, what method and what medical device was used. The format and structure of the ICD-10 codes varies greatly from the previous diagnosis codes.

ICD-9 codes are 3-5 characters in length and the first digit may be alpha (E or V) or numeric. While ICD-10 are 3-7 characters in length and digit 1 is alpha,  digits 2 and 3 are numeric, digits 4-7 are alpha or numeric. This means that ICD-9 was limited to 17,000 diagnoses, whereas ICD-10 allows billing for over 140,000 distinct diagnoses and procedures, based on statistics provided by the U.S. Department of Health and Human Services:.

Information Technology and software will see the biggest impact on the transition. Healthcare billing departments will also have a large impact and further training will need to be done during the transition to ICD-10. Patients will not see an impact.

This sounds too complicated. Do I have to upgrade to ICD-10? Yes, this is mandatory. If you do not upgrade, you can not bill charges. The transition is required by everyone covered under HIPAA.

Why? ICD-10 exists to move your coding and billing practices forward in the 21st century. As comfortable as you may be with ICD-9, those codes are more than 30 years old, and are missing critical information, such as accurate anatomical descriptions, and differentiation of risk and severity among several issues.

How can I go about this change?  While understanding the structure of a basic ICD-10 code is important, a great deal of the change is understanding how to bill more for more complex conditions, as well as to allow payers and providers to keep better track of what they are paying and billing for. You may be concerned about the difficulty of switching to ICD-10. But it doesn’t have to be as hard as you think it might be.

Most new EHR systems have already begun the transition, and when diagnosing a patient using Certified EHR Technology, you will be able to see medical conditions and problems that are new to ICD-10, as well as the ICD-10 codes that match to old ICD-9 conditions. You should be able to use these comparisons to quickly learn the changes, and with the help of a powerful EHR and a good support team to help you implement change, learning ICD-10 should be incredibly easy, likely much simpler than learning ICD-9 was.

There are several resources for implementing ICD-10 on the internet. The American Medical Association has published a checklist online. This is a good start for implementing ICD-10 in your practice!

Further Readings:

Centers for Medicare and Medicaid Services ICD-10 Factsheet

ICD-10 Implementation Guide for Small and Medium Practices

American Health Informatic Management Association: ICD-10 Implementation Basics

More Barriers to Patient Engagement

Posted in Uncategorized on February 27, 2013 by Matthew Levy

In attempting to address the barriers to increasing and expanding the ways patients can get involved in their own healthcare, we need to realize that some of these barriers are not just expansions of communication problems that can exist no matter where the healthcare exchange is taking place, but rather as a result of the way healthcare has changed. In this case, we move outside of the patient-provider realm and into the administration elements that drive healthcare. For the purposes of this discussion, administration can include just about any group or factor outside of the provider and clinical staff, including hospital administrators, as well as IT factors such as the EHR.

There are two groups that stand to benefit the most from a system like the ones that are being proposed by the ONC. These are patients, who can see improved health services, and hospitals, who can cut costs and improve services. This is obviously the major reason to pursue these efforts. Unfortunately, it is not that easy. The type of patient who is likely to benefit most from an advanced role in their own healthcare is one with more medical issues. Frequently, this represents both the elderly and more economically deprived who, not coincidentally, are the least likely to be both computer literate enough to handle their new tasks or even have the appropriate computer equipment.

Hospital administrators and payers also need to ensure that their providers are given the proper incentives and training to take part. The fundamental difficulty in implementing a new EHR is training all of the new users and convincing them to ditch old workflows in favor of a system that they may not find easier. In this case, we have heard a great deal from providers who are unhappy with the EHR that has been forced upon them, and likely aren’t interested in exploring the new features, capabilities, or benefits available to them. In addition, many healthcare organizations do not always pass on all the serious economic benefits of change to their employees; meaning change for change’s sake is the only encouragement.

Ultimately, the need for a system of greater patient engagement is like a microcosm of the structure it finds itself within. Like those who both promote change as it comes with EHR use, there is evidence that these changes are important and can be useful both in terms of improving patient health, improving the healthcare system as a whole, and provider a greater business model that can provide economic benefits. In addition, many providers who are given the proper guidance, training and support to switch to a new system

At the same time however, this is a change that requires a great deal of change in methods and basic practices. For a group of people who won’t necessarily see the benefits to this change right away, this change might be a difficult one to embrace.

Further Reading:

Patient Engagement: http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=86

Tomorrow is the Last Day Eligible Professionals can Attest for the EHR Incentive

Posted in HIT on February 27, 2013 by mfisher527

February 28, 2013 is the last day for Medicare eligible professionals  to register and attest to receive an incentive payment for 2012. $10.7 billion in meaningful use incentive payments have been paid out to eligible professionals. Eligible professionals can receive up to $44,000 through the Medicare EHR Incentive Program (over 5 years).

The EHR Information Center has extended their hours and can assist  providers with questions in regards to attestation for 2012. For assistance, dial 1-888-734-6433 (primary number) or 888-734-6563 (TTY number).

Tomorrow’s deadline is important, because if you, or any of the providers you work with, began using certified EHR Technology in 2012, and met the published meaningful use guidelines, you can begin the path towards receiving payments guaranteed to you under the law. If you have not begun this transition, now is the time to consider it. Visit the Centers for Medicare and Medicaid Services website to learn more about what is required of you, and consider contacting EHR Evolution for more information.

Attestation user guide can be found here


Barriers: Providers and Patients

Posted in Uncategorized on February 22, 2013 by Matthew Levy

There are many reasons why the healthcare system might never reach the potentials being presented by ONC experts and proponents of advancing the doctor-patient relationship to a new level. There are barriers, both large and small, that exist throughout the field, amongst all relationships. Provider-patient is the oldest relationship in healthcare. As long as there have been doctors, they have had patients to treat. This history brings with it an entrenched relationship and some rigidly defined roles. This might include providers who are simply not interested in doing more than is required in the exam room to address their patients’ questions and concerns.

If this was the only limitation, we could work on breaking the barrier by providing hospitals proper levels of training and support to encourage a more open patient provider relationship. The difficulties, however, go deeper than this. Some of the greatest issues, even during an on-site appointment, are communication barriers. Studies have shown that Americans have a lower than average level of literacy when it comes to healthcare. This means they cannot fully interpret information given to them to make proper health care decisions. The only health literacy study done on a national level has shown that 12% of patients are proficient in completing the tasks we consider essential to understanding and acting on healthcare knowledge given to them.

In addition, on the other side, providers frequently do not realize their patient cannot understand. Often they ask the patient a “any questions?” instead of trying to truly ascertain comprehension. People of all classes are reluctant to do anything that they think might expose them as being less intelligent, and what does this more than admitting you do not understand what someone is saying to you? Now imagine the difference between the previous scenario happening in the doctor’s office, where a well-trained provider might be able to see or ask if the patient understands what has just been said, and a remote exchange, or an occurrence like the patient reading highly technical results. This is exactly the type of barrier that might make a patient prefer to avoid an online encounter.

In response to this problem, the Institute of Medicine has suggested that organizations become “health-literate organizations” that is organizations that attempt to present information at all times in a way to help patients with low health literacy understand and use information about their health. This means, for one thing, applying a “universal precautions” approach to health literacy: assuming that low health literacy may exist in all health systems or provider- patient interactions.

The issue as it currently exists is similar to what we see quite frequently throughout Health IT. It is difficult to break out of the everyday routine that has become very easy for healthcare workers. Embracing a new system is difficult, even with the knowledge that it will improve care and make for a better business.  It will require proper support and training for doctors, administrators and patients to break through the inertia.

Further Reading:

Health Affairs: “A Health Literate Care Model”

Institute of Medicine: “Ten Attributes  of Health Literate Health Care Organizations”

Healthcare Providers? Yes,There is an App for That!

Posted in HIT on February 21, 2013 by mfisher527

In this day and age there is an app for just about everything!  New healthcare and medical related applications are being developed constantly. Applications can be downloaded right to your Smartphone, Ipad, Netbook, PC or other device. These apps are geared towards healthcare providers as well as patients.

With over 45,000 reviews on Itunes, Epocrates is a popular resource among healthcare providers. With this app you can review prescription, over the counter and generic drug dosing information, side effects and interactions with other drugs. Pills can quickly be identified by their codes or physical characteristics. Medical news, research, disease processes, lab guides and many other clinical tools come with this application.

iRadiology is a great app for medical students and radiology students. iRadiology allows you to view hundreds of radiological abnormalities, allowing for quick comparison or to find trends. The user can do keyword searches to find medical cases pertaining to radiology, including photos that have a zoom feature. You can even view unlabeled abnormalities and test your own knowledge. This app was created by Dr. Gillian Lieberman, the Director of Harvard Medical Student Education.

Skyscape offers a free medical app, popular among healthcare providers and students in the healthcare field. The free option includes; drug guide, drug dosage calculator, clinical trial results, drug alerts, breaking medical news and a large variety of information on various clinical topics. There are over 600 premium resources in 35 medical specialties that can be purchased for this application. Some of the popular purchases include; Davis’s Drug Guide for Nurses, 5-Minute Clinical Consult, Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology and The Merck Manual of Diagnosis and Therapy. Skyscape is available on multiple mobile platforms, including: iOS, Android, and Blackberry.  Omnio is a recent app made by Skyscape. With Omnio, healthcare providers can customize their favorite medical must-haves in one place. Omnio has similar features as the Skyscape app, but allows the user to be very involved in what is in the app, and in what order.

With Microdemex, healthcare professionals no longer need to carry around a drug guide nor worry about buying the updated version each year. This is a one stop shop for all your prescription and over the counter drug information. This application can easily be installed on your Smartphone, making it very convenient in the clinical setting. Microdemex offers drug interaction, pediatric dosing information, IV compatibility, patient education and tips on patient engagement when it comes to their healthcare.

There are many applications geared towards specialties as well. A quick internet search will pull up an app on just about any topic. Google Play offers apps for Android users.  The Itunes store is a good resource for Mac, iPad and iPhone users. Take advantage of new technology! Ultimately making your work more efficient, this in turn will better patient care. Next week we will take a look at the applications out there geared towards patients.

Barriers to Patient Engagement

Posted in Uncategorized on February 21, 2013 by Matthew Levy

The EHR effort, and patient engagement initiatives in particular, are meant to transform healthcare in a meaningful way. But the concept is not new. While there are different degrees of patient interaction, for example, several hospitals have made efforts to offer patients electronic access to their own records as well as personal electronic communication with their provider. And people have observed that patients with greater involvement in their own healthcare are, on the whole, healthier.  However, as we have pointed out, despite these efforts at larger organizations to create a patient engagement system, the goals set out under Meaningful Use require very little achievement. A larger effort must be made throughout the healthcare system in order to push further patient engagement.

This raises an important question. If so many elements of the healthcare process are interested in pushing patient engagement, what are the barriers to moving forward? To begin to find an answer to this question, we can explore the interconnecting elements that make up the healthcare system. They can be loosely categorized into three: Providers, Patients, and Administrators. Administrators does not just include people running a hospital, but also the people responsible for creating and selecting Electronic Health Records, as well as government elements and those that control the purse strings.

Former surgeon general C. Everett Koop once observed, “Drugs don’t work in patients who don’t take them.” This can apply here as well. If we cannot get patients engaged, we cannot fully reap the benefits of the EHR. Each participant within the healthcare field, as well as relationships and interactions between them, can potentially have its own barriers to moving forward. In the next few posts, we will address some of these barriers.

How Government is Driving Patient Engagement

Posted in Uncategorized on February 19, 2013 by Matthew Levy

As discussed both here and elsewhere, as Meaningful Use goes forward, increasing levels of patient engagement are required.  The latest issue of the journal Health Affairs is dedicated entirely to the idea of promoting patient engagement throughout healthcare. Unsurprisingly, the recent efforts to promote greater use of technology and Electronic Health Records come into play. One article is written by members of the Office of Consumer eHealth, part of the Office of the National Coordinator for Health Information Technology (ONC). They discuss their understanding of why this engagement is important and where we are now.

They then turn to the current federal strategy for increasing consumer engagement with e-health. A major focus is the “Three A’s” strategy developed by the ONC to fulfill its goal to empower people to improve their health and health care through health information technology. The three parts of the strategy are to increase patients’ Access to their health information; to enable consumers to take Action with that information; and to shift Attitudes so that patients and providers think and act as partners in managing health and health care using health information technology.

The implementation of each of these is just starting, but several things are clear: Access alone, even if it were universal which it will never be, is insufficient and that success in this area requires a partnership between patients/providers/government/EHR providers and others in a way that is unique in health care. A “cultural shift” is required on the part of patients and providers. For example, they say  “patients need to feel comfortable requesting electronic access to their health records, asking providers questions, sharing their own health knowledge, and weighing in on treatment options. “ Successful implementation in this area requires acknowledging barriers that may exist at many levels and trying to study and reduce them. This work is just beginning. Going forward, we must address these barriers to a world of greater patient engagement in healthcare.