Immerse Coders in EMR Decisions

by Sheri Poe Bernard, CPC, CPC-H, CPC-P

When it comes to implementation of an electronic medical record (EMR) in your practice or facility, an old adage proves true for medical coders: If you aren’t part of the solution, you’re part of the problem. While it may not be immediately obvious that coders and compliance personnel should be part of a practice’s EMR selection team, once the issue is analyzed, it’s clear a good decision can’t be made without them.

A report released by the National Center for Health Statistics (NCHS) in fourth quarter 2007 showed that the adoption rate of EMRs by office-based physicians was 28.2 percent in 2006, representing a 22 percent increase over 2005, and a 60 percent increase since 2001—the first year of the survey. Medical practices reported a 25.9 percent adoption rate—a 42 percent increase over 2005.

NCHS began monitoring EMR adoption as part of a national goal toward universal electronic health records. The current administration has set goals for conversion of the country’s health care to EMRs by 2015, and the number of systems being submitted for credentialing through the Certification Commission for Health Information Technology (CCHIT) shows a renewed momentum in the health care marketplace.

With an average price tag of $32,000 per full-time physician for an EMR in a physician practice, it’s crucial for practices to make the right choice when choosing an EMR. The benefits of the EMR can be significant:

P4P. Automated preventative care service scheduling ensures patients benefit from best practices and providers are eligible for Physician Quality Reporting Initiative (PQRI) and private pay-for-performance benefits;

Flag errors. Automated edits flag drug interactions, allergies or duplicate prescriptions; All records for encounters, X-rays, lab tests and medication schedules are stored in one place for instant access or reproduction, with back-up records stored offsite;

Insurance eligibility. For services, supplies or drugs, the patient’s insurance eligibility can be displayed;

Efficiency. The automated management of data reduces administrative costs for chart pulls, new patient chart generation, missing chart searches, transcription, lab result handling, referral letters and medical chart supplies.

So who makes the EMR decision?

Certainly, the information technology staff plays a part in making decisions, but most practices see physicians as the decision-makers for EMRs due to the clinical nature of most EMRs’ features and functionalities. The business staff may be granted a seat on the decision-making committee, since many of the features of EMRs focus on scheduling, managing consents and authorizations, managing patient demographics, and generating inter-provider communication.

But most EMRs not only organize and house the patient’s medical record, they also provide pick-lists for ICD-9-CM, CPT®, and HCPCS Level II codes; and many are programmed to select an evaluation and management (E/M) service code based on the medical record.

“Given the number of years that the American Medical Association (AMA) and Centers for Medicare and Medicaid Services (CMS) have been wrestling with documentation guidelines for E/M, an automated system for code selection is a challenge,” says Georgette Gustin, CPC, CCS-P, CHC, PricewaterhouseCoopers. “Because of the complexities of coding, compliance and coding professionals within an organization should fully understand an EMR’s calculation mechanisms for E/M before a purchase decision is made.”

Among key coding considerations in EMR selection are the following:

Cloning. Cloning refers to the automated cut-and-paste of information from a previous patient encounter into the current patient encounter. For example, this can be done within the patient’s medical history. Cloning can also refer to template technology that imports entire sentences or phrases into the medical record at the touch of a button, due to the use of note templates. Both types of cloning are present in many EMRs.

“Cloned documentation does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information,” Gustin says. “It is imperative that processes be established within an organization’s auditing and monitoring program to address cloning.”

Pick lists. Most EMRs provide pick lists of diagnostic codes from which the clinicians may select appropriate codes. The pick list is derived from logarithms that analyze the patient encounter or, more simply, from a list of most common diagnoses for that specialty. In many cases, to keep the lists short enough to fit onto the screen, only “other specified,” “unspecified” or common diagnoses are included, so the best coding choices cannot be made. Pick lists do not contain the notes and inclusion information found in the ICD-9-CM code book, so physicians may not know what is excluded or included within a certain code. Finally, medical necessity edits are an important part of reimbursement, and often are omitted from standard EMRs.

Evolving rules. How are the EMR’s coding rules updated, and how frequently? How does the vendor handle a conflict between CMS and AMA coding rules or guidelines? Can the rules be adjusted according to payer?

CACs. Computer assisted coding systems or CACs are appended to EMRs, and provide automated coding of CPT® procedures, HCPCS Level II supplies and services, and ICD-9-CM codes. If the system your practice is reviewing includes a CAC, the stakes are much higher for compliance risk. Claims that EMRs and CACs will eliminate the need for coders are greatly exaggerated: The current medical reimbursement environment is a complex network of coding and documentation rules difficult to totally automate. A good CAC will increase coder productivity and reduce jobs, but many of those jobs are shifting into information technology, EMR vendor and auditor professions.

Remember that vendors and payers do not indemnify providers against noncompliant coding from EMRs or CACs; the responsibility for correct coding is ultimately the practice’s responsibility.

“Coders and compliance personnel working proactively within the vendor selection and implementation processes can assist in identifying potential coding and compliance concerns early on,” Gustin says. “Work with the vendor to configure the system limitations, features and functionalities you need to be compliant with billing requirements.”


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