CMS & ONC Listening Session: Billing and Coding with Electronic Health Records

CMS & ONC Listening Session: Billing and Coding with Electronic Health Records


Well, good afternoon. I would like to thank Rob and ONC and CMS for having me here today to talk with you, and also for putting me last on the agenda on a Friday afternoon. also for putting me last on the agenda on a Friday afternoon. “[laughter] “I’m well aware that I’m in between you and your weekend, but I am happy to be here and we’re here talking about a very, very important topic. I want to tell you a little bit about HIMS so that you can understand our perspective. We represent more than 50,000 individual members, of which more than two-thirds work for a health care provider, governmental or not-for-profit organization, and we also include over 750 corporate members and more than 225 not-for-profit members that share our vision of better health through improved — through use of information technology. “So, we’ve been looking at this issue for awhile. In fact, HIMS recently gathered some of our stakeholders in an EHR coding integrity work group, and of course, this was in response to public reports indicating that clinician’s use of EHRs may have contributed to inappropriate coding or over-billing, including in the area of evaluation and management services. Our work group performed a critical review of the underlying causes of coding errors in EHRs. At the highest level I’d like to say it’s important to recognize that changes in reimbursements, practice patterns, and/or technology can all create opportunities for coding issues. And the work of this work group really informed our statement today. “So prior to the widespread use of EHRs in clinical practices, providers were often worried about claims of fraud and abuse. Many of our members anecdotally report that their practice would under-code for the encounter if they were not absolutely sure whether they met the complex guidelines that must be followed to select the correct codes, codes that are often also used by commercial payers. But coincident with many other beneficial functions, today’s EHRs can facilitate better documentation, as well as direct selection of diagnosis or procedure codes, and as well as capabilities for computer-assisted coding. So based on the work of our work group and other anecdotal data, we have the following observations regarding the complex factors that can influence the impact of the use of EHRs for coding. First, HIMS members tells us that they are able to code more accurately than in the past. And this perhaps could increase health care costs to the payer, but not to the system overall. That is, in the past, the provider may have been absorbing those costs. Across the health care system, heath IT enables earlier recognition of potential medical problems. So we are ordering more follow-ups and preventative and screening tests. While these efforts may increase costs in the short-term, there exists a potential long-term benefit of decreased cost as we aim for a healthier population, improve chronic disease management, and detect cancer and other conditions at an earlier stage. “As we strive as an industry to increase quality and manage overall health, it’s important to also note that clinical and primary care are evolving, even in our current encounter-based system. For example, one approach, not invented by the EHR, but perhaps made more achievable by EHR systems, is what is called a shared agenda visit. This means that although patients come to the physician as needed for sick care, the physician uses the EHR to identify specific care opportunities and unmet goals. When appropriate and feasible, they can expand the acute care visit to include whatever preventative and chronic care needs the patient might have, depending on the number of those conditions addressed and how they were managed. Under the coding guidelines we have today we might expect that shifting to an outcome-focused shared agenda model might lead to short-term cost increases. “Challenges do exist today for the use of EHR for coding. When the provider is — while the provider is usually in the best position to know the clinical details of a patient encounter, they are often unfamiliar with the complex guidelines that must be followed to select the correct codes. In particular, E&M codes. Still, because E&M is a codification of the diagnostic process in clinical medicine, we must facilitate functionality and interfaces that incorporate E&M principles into optimal care. Our overall goal as a community is that the clinicians are able to incorporate the complex E&M guidelines to promote patient care excellence as one of the benefits of the well-designed EHR. “Finally, challenges with EHR workflows and clinician training may not optimally facilitate the capture of an adequate medical history, including a clinician’s ability to determine accurate and trustworthy differential diagnoses. In the absence of reliable clinical diagnosis, clinicians may often resort to increased diagnostic testing, usually in order to discover a diagnosis rather than simply confirming it or determining the extent. So with respect to these challenges, HIMS recommends that health care community work together in the following three areas: Integrate E&M documentation, training, and oversight in the medical school and residency curriculum. “Simplified CPT E&M codes will ultimately provide more granular and specific guidance for E&M coding. Evaluate ways to specifically identify functional requirements for EHRs that would help facilitate E&M compliance, as well as better documentation and diagnostic work flows, again, with the goal of using the EHR functionality for the benefit of the patient. “As we look towards the future we can anticipate the following. In the area of new challenges in coding, clinical quality measures can lead to additional non-clinically related documentation in the clinical workflow. Future payment models that are not fee-for-service may also drive additional documentation. And with new payment models, in order to say incent uptake of health information exchange capabilities, we may see adoption of new coding capabilities. An example of that is higher E&M coding for cognitive activities, such as information reconciliation in the information exchange arena. “And finally, as we realize new payment models that pay for outcomes or that are bundled, the phenomenon of coding errors related to care encounters may self-resolve. HIMS notes also that the IT market is already providing solutions. Third-party products can provide coding translation outside of the EHR as part of the billing cycle. For example, some new products that are aimed at easing the ICD-10 transition could also possibly address the coding error challenge as well. Companies that provide clinical interfaced terminology content provide clinician-friendly, clear, unambiguous descriptions of diagnoses and procedures, along with mappings to standardized coding systems, ICD-9, ICD-10, CPT-4, et cetera, and these are done by professional coders. This can allow for the best of both worlds, collecting structured data from professionals that are closest to the clinical reality while ensuring that diagnosis and procedure codes that are used for billing are correct. “So, given the work that HIMS has already done in our commitment to working on this issue going forward, we take the issue of coding errors seriously, and we are convinced that convening the community to discuss these issues is a very advantageous activity. We very much appreciate the opportunity to participate here today. We look forward to working with federal government and health care community partners to leverage opportunities to maximize coding efficiency and accuracy, all with the goal of facilitating the optimal use of EHRs in the clinical workflow. So, with that I’d like to say happy Friday. Thanks, again, to Rob, ONC, and CMS for having HIMS here today, and we appreciate it. Thank you. [applause] today, and we appreciate it. Thank you. [applause] today, and we appreciate it. Thank you. [applause] today, and we appreciate it. Thank you. [applause]

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