Docs Manually Code E/M with EHRs

Physicians are adopting electronic health record systems (EHRs) quickly, but they aren’t letting them do most of the work, according to the U.S. Department of Health & Human Services (HHS) Office of Inspector General (OIG). A recent study, outlined in a June 21 report, found all of those surveyed who have EHRs don’t use their systems’ automatic coding modules to assign evaluation and management (E/M) codes.

Of those who didn’t use their EHR’s automatic coding modules, 88 percent coded E/M themselves and 12 percent had staff manually assign codes. Of the 2,000 sampled in the study, the OIG found 57 percent have EHRs in their primary practices in 2011. Of those, 22 percent began using the technology to document E/M in 2011, the year the Medicare and Medicaid EHR Incentive Programs were launched.

Evaluation and Management – CEMC

The study was requested by the Office of the National Coordinator for Health Information Technology (ONC) as part of a related evaluation of documentation vulnerabilities of E/M services involving EHRs. The ONC is expected to establish standards for how physicians should use EHRs to create medical records meeting CMS documentation requests for E/M services.

The OIG said it will evaluate billing fraud related to EHR systems in its 2012 Work Plan.

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10 Responses to “Docs Manually Code E/M with EHRs”

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    It’s actually a cool and helpful piece of information. I’m glad that you shared this helpful info with us. Please keep us up to date like this. Thanks for sharing.

  2. Altess Harris says:

    This information is very helpful to know especially while I’m in the process of seeking employment. It is good to be a member of AAPC and knowing any information received is from a trustworthy source.

    Thank you for continuous updates!

  3. Sherry Ochoa says:

    This is how doctors are. Refuse to let anyone else have control of their billing even when they could be endangering there practice doing it themselves. Or trusting an EHR salesperson instead of the people that have worked for them for 10+ years. It’s ridiculous!

  4. Sharon McBride says:

    I am eager to see the guidelines for ehr documentation. I understand why a physician prefers to code them yourself. There has been many articles written. About cloning notes. Better safe than sorry. Plus I am almost sure that the EMR is coding at a lower level.

  5. Bonnie Wilson says:

    I agree with Sharon, I think most EMR systems code at a lower level. But I believe it is because of free text and the computer can only count what it is structured to count. New users need to take the time to establish a place in thier EMR for the information being put in free text areas. Also you may have to adapt HPI and ROS areas to fix your practice specifically.

  6. Bonnie Wilson says:

    Sorry, I ment fit your practice.

  7. Mary Ann Budzon says:

    It’s my understanding that originally many EMR systems used “canned versions” to choose an EM level of service which was not always correct or appropriate. Isn’t this why Medicare did not approve many of the systems that were available? If EMR is meant to code the EM level for the physician, then what’s next automatic diagnosis, assessment, treatment plan–isn’t there supposed to be physician involvement?

  8. Colleen Fusetti says:

    I think we need to look at both sides of the perspective around this. I have been with many many physicians and practices, specialists and pcp’s, most of who were willing to change old habits. The bottom line is it generally DOES take longer for a doc to click, click click their way through the screens to get to the final documentation product. And- they are at the mercy of the standard templates that are often not what they were used to having. Average of an additional hour added on to their day if utilizing all facets of the EMR; these are docs who were up to speed and willing to participate in the overall acceptance and use factor.
    There is absolutely a need for this and the final end results will be more precise medical records but we must acknowledge- on the whole- there is much work to be done to make it more END user friendly. Additionally, a LOT of consideration to revamping the practice flow has to take place before you go live with EMR. Good stuff- but we must note the overall effort involved.

  9. Angela Thomas says:

    I think there is still a lot of work that needs to be done as far as perfecting these systems. In my experience of auditing several offices on EMR I am seeing a lot of cloning. Also, a popular system in our area can be manipulated to select level 5’s when the visit was a 3 at best. We are also getting many complaints from Doctors about how time consuming the EMR templates are and they feel like they are loosing face to face time with patient’s because they are fighting the systems. I hope there is better technology on the way to help reduce documentation time and provide accurate coding.

  10. Sheri Hicks says:

    I have been training providers and practices on using a specific EMR in their practices for the past 3 years. Most of the providers that I have worked with want the EMR to code for them, because they are not confident in their ability to code correctly. When I train, I point out that all the program can do is “count” structured items to calculate if a ROS, Exam, HPI, etc., meet the number of systems/criteria required to bill a specific level. Most programs have the ability to count the number of systems required based on whether the patient is documented as a new or established patient. Also, most programs feature templates that allow the provider to quickly document a comprehensive ROS, Exam and pull in all Histories for each visit. Consequently,most EMR programs will either over-code the visit if templates are used or under-code the visit code if a dictation program or free text is used. I consistently teach that it remains the provider’s responsibility to base his/her coding on the medical necessity and to over-ride the system suggestion for the EM code if it is not appropriate.

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