What could replace E&M coding to improve healthcare (and EMR)?

A comment on my somewhat controversial thought post about imagining an EMR without billing reminded me that I wanted to ask the question of my readers about what could replace E&M coding. Seriously, I can’t think of anyone I know that actually likes E&M coding. I know some people that are good at it and so they like that they have a skill in that area. However, I don’t remember anyone being a proponent of E&M coding because it provides better patient care or makes life easier for doctors. Am I just missing these reports? So, this leads to the important question…

What could replace E&M coding that would improve healthcare and still handle billing?

Plus, after you read the comment below, you’ll understand why improving billing could also improve many of the billing machines EMR software that’s out there as well. Let’s hear your thoughts.

Here’s the comment that prompted this thought:

The broader problem is that the billing aspects have many more insidiously negative effects than simply sending a charge transaction across an interface.

They actually degrade the quality of the documentation by requiring certain elements to support specific levels of billing. The whole issue of needing to have a certain number of elements done and documented to bill a particular E&M code is one example. A particular visit may have extremely complex history/assessment/decision-making but to get “credit” one also has to document a certain number of irrelevant review of systems items.

It is no surprise that the places that have used EHRs most effectively such as Kaiser and the VA are incentivized to give care that will produce better outcomes. They are less beholden to bureaucratic insurer-driven documentation demands that do not aid in patient care or communication.

Eliminating all of these items (and similar demands for information to fulfill PQRI and other measures that are irrelevant to a particular patient or that fragment thought processes) would improve workflow and efficiency in any system, paper or electronic. It would certainly make it easier to develop an EMR that would support patient care needs.

But just having distinct EMR and billing software isn’t going to do the trick in our current dysfunctional health care system. It is only if an EMR can be designed (and insurer/payor/regulatory demands can be synchronized) so that the health care system looks like a single payer system to the EHR user and clinicians can go about the business of treating patients.

It’s a little bit pie in the sky thinking, but sometimes that’s beneficial.

About the author

John Lynn

John Lynn

John Lynn is the Founder of the HealthcareScene.com, a network of leading Healthcare IT resources. The flagship blog, Healthcare IT Today, contains over 13,000 articles with over half of the articles written by John. These EMR and Healthcare IT related articles have been viewed over 20 million times.

John manages Healthcare IT Central, the leading career Health IT job board. He also organizes the first of its kind conference and community focused on healthcare marketing, Healthcare and IT Marketing Conference, and a healthcare IT conference, EXPO.health, focused on practical healthcare IT innovation. John is an advisor to multiple healthcare IT companies. John is highly involved in social media, and in addition to his blogs can be found on Twitter: @techguy.


  • Oddly enough, we’ve actually heard from some doctors that they WANT E&M semi-automation, because they tend to under-charge to avoid audits. They said they’d like to have some sort of automated assistance so they can tell when they’re in a more comfortable situation to charge on a higher level.

  • Isamu,
    Actually, this has been a common benefit of EMR software for a while. In some cases, people use improved E&M coding (using their EMR’s coding engine to help) as one of the benefits of moving to EMR.

    I remember speaking at one event and a couple doctors talked about their chronic under coding. I think it’s a widespread issue for many.

    Of course, these people would probably love a simpler system even more than those that are maximizing their payment using the E&M coding system.

  • Oh certainly, simplification of these input/output tools is I think a key concern, but I also feel like it’s a key concern for health IT implementation as a whole. I was just commenting that I don’t know that E&M coding can really be “replaced” per se because of how valuable many doctors find it to be.

  • They find it valuable, because it gets them higher reimbursement. If they reimbursement model changed, I don’t know any doctors who wouldn’t gladly switch to a different more simplified or unified billing situation.

    Of course the billing industry people might have some issue with it;-)

  • John, any idea how accurate these E&M coders usually are? I “heard” (unverified) that a study was done somewhere that tested the E&M coders in a bunch of different EMRs and it showed 80+% of them actually coded inaccurately. If true that would certainly be ironic if most users think their EMRs are helping their coding accuracy.

  • We ER docs usually send our charts to a third party to do the coding. They take a cut. And I do stuff my notes with a lot of irrelevant discreet data to make sure I achieve the appropriate billing level for the complexity of the case. You’re never going to get a level 5 from a sore throat though, so I keep those types of notes simple. anyway, good post. I don’t like the current system but I can see how it came to be and i understand it. We tend to be suspicious of anyone wanting to change our reimburement model because that’s really just a code word for not going to pay you now.

  • The real flaw of the E&M system is not what or how H&P’s, ROS, etc. are documented, but how they are interpreted. While the documentation is factual in nature, the interpretation by the coders is quite subjective (likely the root cause of the dismal E&M coding statistics). From my perspective, having established guidelines on documentation is advantageous and would probably prove useful in the IP setting. Having subjective interpretation of the documentation be the determining factor in what is actually billed is where the breakdown really occurs.

  • It is only if …the health care system looks like a single payer system…and clinicians can go about the business of treating patients.
    The issue stated above is no where more apparent than in the Community Health Center space where program funding comes and goes month to month, and a patient’s payer may change day to day. I am absolutely shocked that Providers have to be familiar with every nuance of every gov’t program, and current funding of those programs in order to treat patients. I hear them in the hall asking their colleagues “Is XYZ still funded, or do I need to have this patient return after June for their Mammogram?” Or things like, “Come back next week and I can do A and B for you under the ABC program – but only if your sister comes with you and gets tested at the same time.” Or, “that test result was ridiculously high, but I cannot re-do the test unless I make up (out of thin air) a new diagnosis to get it paid.

    I am just making the point that these particular Providers are amazingly gifted, and manage to serve their patients in spite of the system – not with the help of the system. They have to be mindful of every billing nuance while trying to focus on clinical care…

    These unsung heroes manage to win the boxing match even though they often have BOTH hands tied behind their backs!

  • Coding complications in government healthcare ALWAYS favor the house — CMS guarantees it with lawsuits and whistleblower rewards that could attract dishonest employees. Are you careful who you hire?

    Complications in healthcare informatics – including 5-digit CPT code mistakes as well as foul-ups that involve physicians’ “voluntary” 10-digit National Provider Identifier numbers – ALWAYS grant insurers more time to pay past-due bills owed to their clients and their clients’ doctors.

    Call me cynical, but if interest rates climb ever higher as predicted, watch for unexplained, proportional increases in coding errors to help fund insurance CFOs’ bonuses while raising the cost of healthcare even more without improving value. Is it any wonder why Americans don’t get the quality of healthcare we purchase compared to citizens in other countries? Tax-payers in my neighborhood are begging for in-network providers who put their patients’ interests ahead of insurers’ as much as allowed by insurers’ self-serving rules – without committing fraud. As a general rule, healthcare stakeholders accommodate parasites more than principals.

    Accurate CPT coding may have nothing to do with patient care, but CMS makes it nevertheless important to physicians. Whereas the most innocent NPI foul-ups reliably delay payment and never turn out well for providers, the new fraud and abuse provisions of the Patient Protection and Affordable Care Act can cause an innocent coding mistake on a Medicare claim to land the doc in court with charges of fraud depending on the quality of employees one hires – but only if the error favors the provider and not the payer. In June, David Burda posted “Attorney tells audience to brace for a storm of whistle-blower lawsuits” on ModernHealthcare.com.

    Burda reports that healthcare attorney Joanne Judge, a partner with Stevens & Lee in Reading, Pa., predicts a significant increase in whistle-blower lawsuits simply because the new law makes it far too easy for a dishonest employee to file an unwarranted lawsuit. No longer is there a requirement for the whistleblower, who stands to win money from his or her patriotic effort, to directly witness the crime. That kind of idea could catch on in this economy.

    “The new law also converts accidental Medicare overpayments to providers into potential false claims, Judge said. She said the law considers an overpayment as fraud if the overpayment isn’t identified by the provider and returned to the government within 60 days. Judge said that will require providers to beef up their internal billing systems to detect an overpayment as soon as possible and then send Medicare back its money.”

    What can possibly go wrong with that plan? Thorough background checks on all new employees is increasingly important, doc. For my employment security issues, I’ve learned to depend on Richard at Investigation Research Service out of Dallas. (This is not a paid ad).

    D. Kellus Pruitt

  • Two comments: I’d be in favor of a time-based payment system to eliminate all the problems with E&M coding. But the hourly rate would need to be much better and realistic that it actually currently is. Who spends 180 mins with a patient? Give me a break. Secondly, I assume that all of the mistakes that insurance companies make in denying or delaying payments should be tracked and prosecuted if the percentage of claims/incidents exceeds a very low threshold. Take the power back from the insurance companies, because right now, it always favors the house.

  • Steve,
    I’ve never seen a study on those things, but I know some people who think the automated E&M coding in EMR are terrible. No doubt it’s a relatively difficult thing to program.

    Obviously, I have no interest in reducing doctor’s reimbursement. My motives are good, but I can see how many others motives are as you describe. I’m just interested in lowering healthcare costs and part of that seems to be the overhead to deal with the E&M coding.

    Great story. Thanks for sharing. Good to remember how caring and genuine many healthcare providers are.

    D. Kellus Pruitt,
    “Coding complications in government healthcare ALWAYS favor the house”
    That’s the money quote write there. Not sure how to fix that. I guess that’s part of my point.

  • In an amednews article posted today titled, “Meaningful use rules exempt doctors, not EMR systems” by Pamela Lewis Dolan, it appears that Blumenthal is going to push American physicians toward cloud-based eMR systems.

    “Physicians who want to qualify for stage 1 meaningful use incentives need to have electronic medical record systems that can accomplish all the tasks mentioned under the stage 1 rules — even the tasks doctors plan to defer accomplishing until a later time.”

    As pointed out in the article, with a cloud system, functions can be added or removed with no hassle. Whereas proprietary systems are one-size fits all – package deal

  • Here’s the last paragraph from the article you reference D. Kellus Pruitt:
    “Drazen said one solution to this problem is to use a Web-based system, many of which offer an a la carte-type subscription package that allows users to turn off functions they may not need. Because the function is available, the EMR system will meet the requirement without the burden of purchasing a costly system, she said.”

    Umm….this person doesn’t have much of a clue. Even many of the client server systems have a la carte the way she describes it where certain features can be turned off.

    Most web based systems are sold all in one as much as client server. Certainly most web based are a monthly cost instead of a lump sum payment, but I know plenty of client server EMR where you can pick and choose the functions you buy.

    I guess it raises an interesting question. Do you have to actually buy the full certified EHR, or if you opt out of certain features can your EHR have that feature and you just not buy it? The answer of course is that no one is really going to be checking (at least for stage 1), so each EHR vendor will choose their policy in this regard.

    One thing does seem clear. Web based EMR are really taking advantage of the PR message that ALL of their users are on their certified EHR system (once they’re certified). It’s a nice message. Especially for anyone who’s been involved with upgrading a client server EMR (not to mention the hidden costs they like to sometimes throw in for the upgrades).

  • All;

    We definitely feel your pain. We have been in the Health care arena for the past 15 years. We have developed an EMR that has E&M coding built in. If anyone would be interested in seeing our software, Please contact me at azahir@idbsonline.com Thanks;

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