Electronic health records (EHRs) have now been implemented in the vast majority of physician practices in the United States. As a certified coder, auditor and physician educator I’ve been actively involved in this process for years. Healthcare is without question evolutionary. But the implementation of EHRs is one of healthcare’s greatest revolutions affecting both the clinical and business aspects of medicine. As an example, let’s take a look at how EHR implementation has affected outpatient Evaluation and Management (E/M) services.
E/M documentation, coding, charge capture, audit and the related follow up education have all been deeply affected by the implementation of EHRs. Healthcare continues to shift away from inpatient to outpatient services and payment methodology continues to shift from fee-for-service to risk and quality of care based reimbursement. Additionally, physician practices are being incorporated into facilities. Given these circumstances it is important to appreciate history as we consider the future so that we are poised to address change effectively.
Not so long ago a physician would see a patient, document the encounter by hand-written note or dictation and enter procedure and diagnosis codes onto a hard-copy “superbill”. A qualified (hopefully!) medical coder reviewed documentation and physician coding for each encounter. Ideally, coders and physicians collaborated to address any documentation and physician coding discrepancies and finally a compliant claim would be generated.
Today most physicians document E/M encounters and assign codes using EHRs. Most EHRs include a billing interface that generates claims automatically based on coding assigned by the physician. At best, a qualified coder spot checks for documentation and code assignment discrepancy, but the expectation is that physicians document comprehensively and assign codes accurately. Of course, a well-run practice also has an audit schedule in place, with effective follow-up education, as part of its compliance plan. Ideally coders and physicians work collaboratively toward compliance and revenue maximization but even the most robust audit schedule reviews only of fraction of encounters for which claims are generated. Clearly, much is expected of physicians. There is no longer a coder acting as a “filter” through which documentation and coding passed prior to claim submission. For this reason it is imperative that physicians have a deep understanding of documentation/coding guidelines and the technological knowledge that allows them to use the EHR most effectively.
Most EHRs have tools that prompt physicians to capture E/M key components and their elements. However, E/M compliance and revenue maximization still requires that physicians:
- Know the E/M guidelines
- Understand that medical necessity must drive the level of E/M service
- Know how to appropriately score E/M services and assign procedure codes
- Know how to use the EHR effectively to document only accurate, applicable and meaningful content
Of course all but the last bullet were important considerations prior EHR implementation.
Another issue emerging related to outpatient E/M services is diagnosis coding. While accuracy is important, historically diagnosis code assignment for E/M services has not been a reimbursement consideration. However as physician payment models shift from fee-for-service to risk and quality of care reimbursement, it is essential that documentation and coding include more robust information related to illness severity and comorbid conditions. Of course the adoption of ICD-10 allows for capture of greater diagnostic detail but along with this detail come more complex code assignment guidelines.
Since the implementation of the Diagnosis Related Group (DRG) payment methodology for inpatient services in the 1980s, clinical documentation improvement (CDI) efforts have been established to optimize capture of illness severity and comorbidities. One of the advantages to facilities incorporating physician practices is that these institutions have clinical documentation optimization experience. Still, outpatient healthcare has its own unique set of guidelines that must be learned by CDI specialists and then taught to physicians. It is also important to note that, while physicians are expected acquire documentation skills that optimize inpatient code assignment, they are not required to actually assign the codes. As the importance of diagnosis code assignment increases for outpatient services it will be interesting to see where responsibility for code assignment falls.
Healthcare is continually evolving. The EHR itself influences some aspects of this evolution while assisting with other aspects of it. Innovation and flexibility have always been and will remain key to a successful healthcare delivery system.