Since practices in the U.S. have begun using electronic health records (EHRs), reimbursements have risen nationwide for office visits. “When we begin an EHR implementation, I will tell practices not to be surprised at seeing a higher level of service coding than what there’re used to,” Gulledge says.
The rise stems from the ease of recording actions normally not charted when paper was the medium. But EHRs present lists, so noting that the ears have been checked or the heart listened to requires only a click. “Now physicians are getting credit for work they’ve done for years and years, and just not ever gotten paid for,” Gulledge says.
The fiscal outcome of utilizing an EHR effectively for coding can be notable. A pediatrician who Gulledge worked with in south Alabama implemented his EHR last year. “He never billed out an office visit at 99215, which is the highest level, and he should have been. But he was worried about audits,” she says.
Over the first six months of using his EHR, his reimbursements rose over $30,000. “Because he could accurately code,” Gulledge says. “He’d been seeing some really sick children all along, so he should have been having the higher office visit codes.”
Practices should not hesitate to trust reliable EHR’s to help with codes. “It’s just math,” says Mary Elliott, CPA, with Warren Averett Kimbrough & Marino. Because EHR recommendations for service codes are based solely on whether the actions documented by the physician and nursing staff match the bullet points required by the 95 or 97 coding guidelines.
But EHR recommendations are not perfect. “A lot of times, the physician is meeting the documented guidelines to get the high level of service code, but the medical decision is not high enough to warrant that code,” says Misty Walker, executive vice president with Code+Collect. “So if you’re audited that will cause an issue.”
For example, a patient with knee pain sees an orthopedist. He is a new patient, so the physician does a complete review of the systems and all the histories. “They hit every bullet point for a high-level visit during the exam,” Walker says. “But the orthopedist surgeon decides to do nothing for the patient, because it’s chronic osteoarthritis and the patient is too young for surgery. So according to the EHR, it could code as a high-level visit, but since nothing was done to the patient, it would be a low-level bill out.”
The EHR can also recommend a lower code than what was earned when physicians and nurses perform actions outside the time spent with the patient. “If I’m an internal medicine physician, and I call a cardiologist about a patient and discuss the plan, the system can’t know that I did that work,” Gulledge says. “Physicians must keep the EHR up on what they’re doing, so that at the end of the visit, their documentation triggers the right code.”
Unfortunately, physicians fear audits so strongly they cheat themselves. But Walker says, “It’s not ‘if’ you’re going to be audited, it’s just ‘when.’ So code for the work you do.”
She says follow-up visits top her list of unnecessary undercoding by practices. “It takes very little to qualify for the 99213 code, and yet physicians regularly use the 99212 instead just to feel safe. But most of the time, the higher code is appropriate,” Walker says. “That code difference could mean $10 to $15 per visit they’re losing and that’s a significant loss over a year’s time.”
Jim Stroud, CPA, with Warren Averett Kimbrough & Marino, warns that repeated diagnosis codes can throw up red flags to auditors. “If the patient is a diabetic and presents repeatedly, physicians often just put diabetes as the diagnosis code each time. But there’s limits to how often you can bill for the one diagnosis unless they’re presenting with complications,” he says. “So the code has to be a diabetes diagnoses with something, and physicians have to articulate that complication. That then justifies a higher visit code.”
Stroud also points out that to fully take advantage of the coding option offered by EHRs means ensuring the software is set up to suit the practice’s needs. “The system creates the charge form based on what you enter,” Stroud says.
So the effectiveness of the EHR, he says, all depends on physicians making the effort at the point of purchase to create accurate templates and understand how the EHR documents their actions. “They need to make their EHR as near to a point-and-click as possible for their needs,” Stroud says.
All agree that practices need to fear auditing less and utilize the logic of their EHR more when it comes to coding. “And everyone’s coding out higher right now as they transition to EHRs, so a sudden jump in your coding isn’t the red flag it used to be,” Gulledge says. “If you’re actually doing the work, then click the button and get paid for it.”
