EHRs Pose Challenges, Provide Opportunities

By Michael Stearns, MD, CPC, CFPC
A recent survey published in the New England Journal of Medicine found that only approximately 17 percent of U.S. physician offices are using electronic health records (EHRs). EHRs are an important part of a federal plan to improve the quality and cost effectiveness of healthcare. The American Recovery and Reinvestment Act of 2009 signed into law by President Obama on Feb. 17 allocated an estimated $34 billion to be used by the Centers for Medicare & Medicaid Services (CMS) as incentives to increase the adoption of EHRs. Individual physicians can qualify for $44,000–$62,000 in incentives for using certified EHRs in a “meaningful” way. To qualify as meaningful use, the EHR must be capable of sending and receiving codified data to other EHRs and disease registries through health information exchanges (HIEs). The current administration stated that their goal is to have more than 75 percent of physicians become meaningful EHR users by the year 2017. Starting in 2015, there will be penalties in the form of reduced Medicare payments for physicians who are not using EHRs.
As EHR adoption rates increase, coding professionals will be presented with new challenges and opportunities requiring increased knowledge about health information technology (HIT)—in particular, how codified data generated by EHRs is managed for billing and reporting. Many of these opportunities represent relatively minor changes in professional coders’ skill sets.
Here are just five examples of how coding professionals can benefit from playing an active role in health care’s evolution into the digital era.

1. Assist Practice Evaluation of EHR Coding Tools and Content Prior to Purchase

The majority of EHRs offer tools to assist clinicians with documenting and determining which evaluation and management (E/M) code should be assigned to an outpatient visit. Because E/M services are the primary source of revenue for the majority of physician practices in the United States, coding professionals can help evaluate how an EHR under consideration by a practice generates suggested E/M codes and modifiers. EHRs also offer content and tools to assist with improved charge capture, ensure CPT^® codes are supported by correct ICD codes, and identify payer specific billing requirements. An in-depth evaluation of how information is added to each visit note through automated processes, such as the reuse of information from old notes, templates, patient entered data, etc., is a critical part of each EHR evaluation. Certain systems may encourage users to add inaccurate information or to include information that was not obtained on the appropriate visit date, putting clinicians at risk for committing fraud. Nuances surrounding the use of 1995 vs. 1997 Documentation Guidelines for Evaluation and Management Services should also be explored, as many systems may only support one type of examination type.

2. Provide Ongoing Coding Support for EHRs during Implementation and Usage

EHRs generally support the incorporation of specific billing codes within the clinical content (e.g., templates) used by clinicians to determine what codes are used for billing processes. Coding professionals should carefully review the clinical content provided by EHR vendors and developed by their facilities for accuracy and completeness. When familiar with the application, sophisticated users can take full advantage of the EHRs ability to support clinician billing activities at a more granular level. EHRs typically allow for payer-specific template creation and related tools to address complex billing scenarios and challenges, such as payer-specific coding requirements. This can lead to significant decreases in denials and can improve the efficiency of the billing process. Numerous challenges exist with how EHR tools calculate E/M coding levels and how clinicians use this information when determining the E/M service level. As with any software application, automated E/M coding tools are only effective and accurate if used properly. Ensuring that clinicians using EHRs remain adherent to accurate coding principles will require ongoing diligence from coding professionals.

3. Facilitate the Implementation and Use of Advanced Medical Terminologies

For the quality and efficiency of health care to improve, a much greater percentage of clinical information needs to be captured and stored as codified and structured data. This offers marked improvements over free text as computers can process codified information in a way that greatly facilitates reporting, clinical decision making, information sharing between health care enterprises, and researching. This process becomes far more powerful if what is referred to as a “reference terminology,” like Systematized Nomenclature of Medicine – Clinical Terms (SNOMED CT), is used. Reference terminologies obey strict rules and are designed specifically for use by software applications, making them far more useful to computer applications than administrative terminologies such as ICD-9-CM or ICD-10-CM. Over the next several years, certain payer programs, such as pay-for-performance, will likely start requiring reporting using SNOMED CTR and/or other reference terminologies. Modern EHRs are capable of storing information as SNOMED CT codes; however, linking clinical information in EHRs to reference terminologies requires a great deal of coding expertise. Professionals with in-depth coding knowledge will be needed to map the information within EHRs to ICD-9-CM and ICD-10-CM, HCPCS Level II, CPT^® codes, SNOMED CT, and other supported terminologies.

4. Provide Data Exchange Support between Healthcare Enterprises

A major requirement for “meaningful use” of EHRs is the ability to share information that is converted into codified clinical data using standard code sets such as ICD-9-CM and, eventually, SNOMED CT. This has the potential to significantly reduce medical errors and to improve the efficiency of healthcare. Considerable challenges remain, however. Information that is exchanged needs to be accurate and complete. Validating the integrity of codified data shared through health information exchanges requires extensive oversight by health care professionals with coding expertise.

5. Assess Clinical Reporting for Compliance

For physicians to become meaningful users, they need to submit reports that document their ability to meet specified clinical objectives (e.g., what percentage of their patient population has undergone recommended preventative screening tests). In addition to the incentive funds tied to meaningful EHR use, there has been a shift in reimbursement towards pay-for-performance programs designed to reward clinicians for providing high quality care. Another challenge is that these guidelines, of which there are hundreds, are rapidly increasing in number and are subject to frequent modifications. For this process to be efficient, the codes contained within EHR content that are used to collect guideline information will need to be updated on a continual basis. Constant vigilance will also be needed to monitor the ability of clinicians to assess compliance with clinical guidelines. This will require detailed knowledge of how codified information is captured in EHRs, stored, and processed by applications. This is an ideal role for individuals with coding expertise.
Michael Stearns, MD, CPC, CFPC, is a board certified neurologist with 15 years of experience in clinical and academic medicine and over 10 years in the areas of HIT and coding. Dr. Stearns has presented on medical terminology, EHRs, coding, and genomic medicine. He has worked on several projects involving computers in medicine at the National Institute of Health and was a key contributor to the development of SNOMED CT. A member of the AAPC Family Practice Steering Committee, he is president and CEO of e-MDs, Inc.

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