An editorial in last week’s NEJM suggests that it’s time we redefine how physicians bill for office visits using E&M (Evaluation and Management) codes, primarily because E&M coding rules have driven the development of an electronic medical record (EMR) built more for the medical coders and bean counters than for clinicians.
The detailed guidelines often cause clinicians to overdocument, making the medical record an ineffective source of communication. To address the elements specified in the guidelines, some clinicians are tempted to engage in extraneous clinical activity to justify using higher code levels and reaping excessive payment. Other clinicians, fearing sanctions for misrepresenting the contents of a medical visit, may downcode their services. Still others blithely ignore the code definitions and guidelines and continue to code according to their own assessment of the value of their E&M services; unless their coding patterns are aberrant, their claims go unchallenged.
It’s the EMR, not E&M, which is the problem
The EMR doesn’t work because it was on the whole designed by non-clinicians.
Yes, current coding rules have driven much of what we document in the EMR, but it’s also meaningful use and PQRS, e-prescribing, patient safety and the desire to create a powerful data repository that has allows us to do things like trend laboratory values, perform clinical research and target health education and marketing.
Changing E&M coding to get documentation right is letting the cart lead the horse. Lets design a electronic note that works clinically, then decide how best to charge for the work of the visit.
The EMR does not cause up-coding
Yes, there are fraudulent docs out there. And yes, the current E&M System is far from perfect. But the latter did not spawn the former. And the former will be the former irrespective of how we define E&M levels of service.
The EMR does not cause E&M upcoding and here’s why – the volume of documentation alone doesn’t drive billing. There’s a little thing called “medical necessity” that ultimately determines the level of billing in E&M. No matter how much I do and document, if it wasn’t necessary at that moment to take care of the patient, I can’t bill for it. CMS knows that, we know that, and our coding reflects that.
I’d argue that it’s learning how to code that allows docs reimbursement to rise, irrespective of EMR use. This is not because docs are gaming the system, but because they’ve finally learned that no matter how well they took care of a complicated patient, if they forgot to document a single element in the review of systems, they don’t get paid. So now that we’ve learned the rules of the game and how to use the EMR to capture every little thing we do so they can’t say we didn’t do it, they want to switch it up again.
Just because it’s documented doesn’t mean we need to see it.
The biggest issue I have with the EMR is not the data it collects, but the data it displays. All I really need to see on a regular basis from my visit notes is my assessment and plan – the rest can be clickable and viewable if I want to find it (or the bean counters want to count it). That’s a quick and easy fix that won’t require a Senate committee and majority vote in Congress.
Exclusively Time-Based Billing is Not the Answer
The authors suggest that time-based billing as a possible alternative to the current E&M system. While we already use time-based billing for visits where counseling and coordination of care dominate, I cannot imagine how I could use it for all my encounters.
I sometimes have three rooms going at a time – one patient in the bathroom giving a urine sample, another in my office and a third in the stirrups. I may pop into the exam room to do a pelvic, then while that patient is getting dressed, see another, then see the first patient back in my office for an extended discussion while the second is getting dressed, etc. How am I supposed to accurately measure the time I’ve spent each of them? A stop watch? And what happens to time-based billing when a physician extenders are used in tandem with physician in an office visit to increase practice efficiency?
In a time-based system, what allows physicians to get paid for the extensive out of visit care time that can results from a complicated office visit? There are many complicated patients whose office visits that don’t involve much face time, but spawn large amounts of follow up time for abnormal test results, calls to radiologists and phone calls back to the patient. The current system of basing reimbursement partly on complexity and medical decision making, while not perfect, does give at least some compensation for this kind of time intensive follow up.
Finally, time-based billing could lead us back to the time of the clinically useless short note – “All is well, f/u 1 year”. Some clinicians I knew could amass 10 years work of a patients’ visit notes on a single double sided 5×7 card. While such a note may work in a small town private practice, it is completely useless today.
I say leave the current E&M system alone for now
It’s taken us years to get E&M coding right. Years. This is not simple stuff, folks, trust me – I’m my departments Billing Compliance Leader, and even I get it wrong sometimes. But I’ve been reviewing my colleague’s charts for over a decade now, and I can tell you that overwhelmingly docs are finally getting it right.
Please, don’t change it up on us now, especially while we’re in the midst of learning meaningful use and PQRS and ICD-10. We’ve got other things to do, you know.
Like take care of patients.
E&M is incredibly complex and is inextricably linked to the Medicare resource-based relative value system, too! In 2000, there was an aborted attempt at updating E&M. Using computer tools like http://www.speedecoder.com can really be helpful for reinforcing good behavior. NEJM gets it wrong saying that docs document superfluously. E&M only counts the documents that defines the E&M. Docs should just learn the guidelines and document correctly and effectively.