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Sunday, October 14, 2012

An Insider's View on Upcoding and the Center For Public Integrity's Article on 'Cracking the Code'

The Center for Public Integrity has a piece titled "Cracking the Codes" which is making waves in the medical world over the last several weeks, as it has revealed data indicating a massive increase in Medicare billing by hospitals and physicians ever since the federal government began incentivizing physicians and hospitals to start using Electronic Medical Records (EMRs).
The immediate (and understandable) fear is that doctors are abusing the built-in efficiencies of EMRs to over-document and/or over-bill. For novice readers unfamiliar with ER billing, here is a quick primer: ER charts are coded into 5 separate categories (plus a sixth for critical care), based on the complexity and risk of the case. The complexity and risk is derived from the ultimate diagnoses, the number of history (the patient's version of his complaints) elements involved, number of physical exam elements (number of body systems examined) examined, and the medical decision making (MDM). MDM is complex, but essentially describes how much thinking, researching, communication, and risk that the case involved. Most ER physicians document the chart, while a separate coder codes the chart; the coder reviews the chart and assigns a billing level to it.
As a physician who began his training and practice during the not-too-distant era before the ubiquity of EMRs, I can tell you that as reimbursement rates have plummeted, and the number of uninsured has sky-rocketed, the focus on documenting fully and accurately has intensified dramatically. There used to be a time when graduating ER residents knew little about RVUs ("Relative Value Units", essentially the number of points assigned to each type of billing level or procedure, which translates directly into dollars). But now, every graduating high-energy resident is looking for an ER job with "RVU based pay" instead of an hourly rate. On an RVU based pay structure, the more patients you see and the better you document, the more you earn. Before the cynics jump on this idea and butcher it, let me just explain that RVU based pay is part of the reason you can walk into any one of our EDs and be seen in less than 30 minutes these days, whereas waits of several hours were the norm in the past. In the past there was no financial incentive for ER doctors to see the next patient, only additional work and risk. Now, ER doctors are eager to not only see the next patient, but also take care of the high risk (and therefore higher RVU) cases. RVU based pay, I argue very strongly, has played a significant role in improving patient safety by clearing out waiting rooms, and incentivizing doctors to see the higher risk cases.
With this growing push to see more patients, see them more quickly, and achieve stellar patient satisfaction results, EMRs have focused on reducing the documentation inefficiencies present with handwritten charts. Imagine hand-writing or typing the same 2 page letter 25 times a day, with just 5-10 sentences different in each letter. How much time would that give you to actually talk with patients and families and to focus on medical decision making? I have a normal full medical exam that I perform on every medical patient I see ("medical patient" refers to complaints such as abdominal pain and chest pain), the same way a baker prepares his dough the same way each day, or a housekeeper has his cleaning sequence, or a teacher gives the same Magna Carta lecture each year. Rhythm is a very powerful force that gives assurance of quality and consistency (two things *every* industry seeks). EMRs have been incredibly helpful in  recognizing that a lot of our documentation is redundant, and creating solutions to help reduce wasted time and effort in reproducing the redundancies. This has resulted in *tremendous* increased productivity by ER physicians, allowing them to see on average 2-2.5 patients per hour in the ER, where 10-15 years ago they were seeing barely 1.5. You can not underestimate how important this increased efficiency is: just talk to families of patients who crashed or died while waiting for hours in waiting rooms of yore.
What is the cost of productivity based pay and the increased efficiency brought about partially by more advanced EMRs? Charts are much more complete than they used to be (RVU based pay incentivizing doctors to documenting everything they do) and they look a lot more similar than they used to (EMRs allowing us to easily replicate the 90% that is the same on many patients). Whereas in the hand-written past there was some variability in the documentation of the 90% that I do which is the same on each medical patient, now there is very little to none. This, the Center for Public Integrity attacks as chart cloning. I see it as the byproduct of yet still inefficient documentation systems trying to relieve some of the ever-growing *massive* documentation pressures on doctors that distract from what is actually important: sitting with my patients and families, listening, and providing care and reassurance.