copy and pasted from other parts of the
record, or from different patient records,
can inadvertently make the patient look
more complex or suggest a more com-
prehensive physical exam than was true
for that specific patient.”
The pitfalls, however, have not been
lost on the compliance-sensitive indus-
try, Bowman says. “Providers and hos-
pitals are stepping back, establishing
policy and procedures. They are working
with EHR vendors to put in some restric-
tions so these features cannot be indis-
criminately used—the copy and paste
features are not by themselves inappro-
priate, but if they’ve used excessively or
incorrectly it can cause unintended con-
sequences.”
Unfair assessment?
Bowman also agrees with Atwal that under-billing was routine prior to EHR deployments. “There has been a lot of under-billing in the past due to incomplete
documentation,” she says. “But there are
other variables driving up reimbursement. Patient conditions are becoming
more complex. Just because reimbursement is higher doesn’t mean it is wrong
or fraudulent.” She calls on HHS to conduct more research in the matter.
The HHS letter caused many in the in-
dustry to bristle. “The letter was an unfair
assessment of how the vast majority of
physicians are utilizing EHRs,” says Lyle
Berkowitz, M.D., medical director of in-
formation technology and innovation at
Northwestern Memorial Physician Group,
a Chicago-based primary care group prac-
tice of 120-plus physicians. Since 2002,
the group has been documenting on an
ambulatory EHR system from Cerner,
with billing done via interface to another
system. “EHRs do indeed enable more
appropriate coding. But just because that
may result in higher coding, it should not
be assumed to be upcoding.”
In his primary care practice, physi-
cians see many patients with multiple
chronic conditions, Berkowitz says. And
thanks to the efficiency of the EHR, they
are able to accomplish more in a single
visit, heeding alerts and reminders that
a patient may be due for a test or evalua-
tion not related to that particular visit. The
work performed at the practice is catego-
rized under an “evaluation and manage-
ment”—or E&M—coding system which
assigns individual visits to a certain level,
with 1 being the lowest and 5 reserved
for the most difficult cases. Assigning the
right level is driven by a complex, multi-
tiered formula that includes the extent of
the exam given, the history reviewed and
overall medical-decision making.
