The study was widely praised within the technology industry and helped persuade Congress and the Obama administration to authorize billions of dollars in federal stimulus money to help hospitals and doctors pay for the installation of EHR systems. These financial incentives have enticed more than 340,000 providers to digitize their medical records. Nearly 60% of practices are now using some form of an EHR. However, the expected savings for the U.S. healthcare system have yet to accrue.
Several reasons may account for this: First, most EHR systems are highly efficient in capturing all forms of medical billing. In fact, this feature has been one of their key selling points. Tuberculosis skin tests, venipuncture, vitamin B-12 injections, throat cultures—you name it—all of these minor charges along with the high-cost procedures will be captured and billed with these new systems. No crumbs will be left behind. Because digitization makes it easy to retrieve notes, supporting data are never lost, and insurers can no longer rely on sloppy record keeping as a reason to reject claims.
Second, any electronic record system provides ample opportunity for clinicians to embellish their notes by using the cut-and-paste keys. A couple of clicks and voila!, a simple office visit can be transformed into a lengthy evaluation, replete with extensive organ system reviews and long-winded family and social histories that help qualify for higher payments. We have all read these repetitious paragraphs that attempt to justify the need for a higher level of payment for the visit. This calculating behavior, better known as upcoding, has spawned a whole new industry of third-party reviewers who try to identify this practice. For a fee, claims reviewers are paid to sift through notes in search of these pastings. They also hunt for specific words that may affect the level of reimbursement. For example, using the term extensive, rather than comprehensive, to describe a careful review of multiple organ systems can lower the payment from a level 4 to a level 3, even though any standard thesaurus might consider these two words to be identical. This modest difference in reimbursement, multiplied over the course of a year’s billings, translates into big bucks and explains why the audit business has become such a lucrative one.
There’s a Code for That!
Of course, no note is complete without an assigned International Classification of Diseases (ICD) code. Although most countries have advanced to the 10th version of this system, the ICD-9 lives on in the U.S., at least for another year. ICD-9 is like an old car: a reliable and steady workhorse that gets you where you need to go. On the other hand, ICD-10 is the flashy sedan; it stores 68,000 codes under its hood, compared with the paltry 13,000 of its predecessor.
