Putting Pressure on EHR Vendors.

In the 1890s, Butch Cassidy and the Wild Bunch robbed slow trains using fast horses and six-shooters.

Today, the government is hinting that hospitals and physicians are robbing Medicare at the speed of electricity, using electronic health-record systems and billing software.

The head of the American Hospital Association, in a Nov. 12 letter to HHS and the U.S. Justice Department, said the AHA wants to join forces with the feds in designing an EHR advisory group on billing codes. The letter was the AHA’s second response to a letter sent to several hospital associations by HHS Secretary Kathleen Sebelius and Attorney General Eric Holder warning them of “troubling indications” that some healthcare providers are using EHRs “to game the system.”

The AHA’s initial letter, while saying practices such as upcoding “should not be tolerated,” asserted that higher reimbursement made possible by more accurate coding with technology does not equate with fraud. AHA President and CEO Richard Umbdenstock also reiterated the association’s repeated calls for coding guidance for evaluation and management services.

The newer letter also seeks to shift attention to the role of EHR vendors in the claims spikes that are drawing attention.

A study this year by HHS’ inspector general’s office found that Medicare payments for the highest levels of evaluation and management services, which vary according to the complexity of the exam, increased significantly between 2001 and 2010. Investigative news reports later suggested a connection between increased Medicare payments and providers receiving incentive payments to use EHR systems. HHS’ inspector general’s office is investigating whether EHRs are driving Medicare E/M billing.

The AHA is now recommending that HHS, in addition to providing more guidance, create “test beds” to ensure EHR vendors develop systems that are “consistent with existing coding conventions.” Umbdenstock also said in the letter the federal government should consider “urging” EHR vendors to adopt a code of ethics similar to the American Health Information Management Association’s “Standards of Ethical Coding” and incorporate pledges to adhere to that code in the certification process for vendors of EHRs used in the incentive payment program.

Since 2011 when payments began, the CMS has paid out $7.7 billion in EHR incentive payments under the American Recovery and Reinvestment Act of 2009. The program is expected to cost taxpayers as much as $27 billion.

Before passage of the stimulus law, EHR vendors’ sales staffers frequently sought to overcome physicians’ objections to the high cost of an EHR by claiming their systems would produce a return on investment. Those returns could be obtained, the sales pitches went, by enabling providers to bill at higher E/M levels, and thus receive more money, because they would have complete and accurate records. The pitches were based on an assumption that physicians were consistently shortchanging themselves by defensively undercoding because of lost or incomplete paper documentation.

“I really think there is a lot of speculation, and what we really need is real research,” said Sue Bowman, senior director of coding compliance at AHIMA, the Chicago-based association for health information professionals, including medical-record coders. “Is the billing actually inappropriate, as it has been claimed?” she pondered. “Or, is it that the EHRs are doing what they have been built to do, more complete and thorough documentation. And so, maybe some of that higher billing is good and should have been there all along and wasn’t.”

With the recent rapid adoption of EHRs because of the federal incentive program, there “may have been some unintended effects,” she said. “We’re sort of in an era now where technology has progressed faster than policy and standards have.”

A key variable in E/M coding is how fully a physician conducts a physical examination of the patient, from a problem-focused exam limited to the affected body area or organ system, to a comprehensive examination of multiple systems. Indiscriminate copying of past patient histories might be another way for providers to “game” one element of the E/M coding criteria.

Some EHRs have templates that pre-load with typical reviews of body systems. “If the template is coming in and it’s all filled in and he has to click on the ones that he didn’t do, there is a high likelihood that he’s going to glance over things that he never really did,” Bowman said.

AHIMA this year published a “copy functionality tool kit” to guide members if called on by their hospitals and physician offices to help develop “copy and paste policies and procedures.”

One of the things vendors could do is spend more time with health information managers when developing their systems, Bowman said. Health information management professionals “with the knowledge of proper record-keeping” could help vendors create technology “that it is not leading people down a path where they should not be going.”

Vendors of EHR systems also recognize that technology is changing the charge capture environment, said Mickey McGlynn, senior director of strategy and operations for Siemens Healthcare. McGlynn is chairwoman of the Electronic Health Record Association, an affiliate of the Healthcare Information and Management Systems Society, a health IT industry trade group.

There is a “fundamental shift” under way “toward capturing clinical quality information as part of the clinical workflow, and away from abstraction, which has historically been the basis of many of the current coding guidelines,” McGlynn said. With the EHR incentive payment program and its emphasis on achieving and documenting meaningful use of EHRs, “all of the information required to properly document patient care and, in turn, support more useful quality and outcomes data, as well as accurate billing” can be gathered as part of normal clinical activity.

“We would be delighted to collaborate with HHS, the AHA and other industry and government stakeholders to provide a better understanding of how our members’ products can support our customers to complete clinical documentation and enable accurate coding and reporting of quality measures,” McGlynn said.