Most Doctors Manually Code Despite EHR Automated Coding

Pamela Lewis Dolan has a great article in AMA’s American Medical news about the automated E&M coding using an EHR versus manual E&M coding. Here’s a quote which sums up the article:

The Dept. of Health and Human Services Office of the National Coordinator for Health Information Technology asked the Office of the Inspector General to prepare a report looking at how Medicare physicians use EHRs to assign and document codes for E&M services. The report found that 57% of Medicare physicians use an EHR, and 90% of them use their systems to document E&M services. But most physicians still assign those codes manually, which could mean they are undercoding services that could qualify for a higher pay rate.

I’ve started seeing more and more people talk about this subject. It’s an amazing switch since one of the initial selling points of EHR software was this powerful E&M engine which would help them to ensure that they’re coding their office visits properly. In fact, many argued that with an EHR they were able to code at much higher levels than they could on paper.

In some ways, I think this can still the case if done right. The rationale is that many times a doctor would evaluate something on a patient, but not take the time to document it in the paper chart. Since they didn’t document it on the paper chart they couldn’t code for it. I’ve heard doctors say that thanks to quality EHR templates they’ve been able to document more of those “extra” items and so they can properly justify the higher code.

Obviously there are a lot of questions and risks associated with what I describe above. The most important being that many achieved the above result by using blanket templates which even included things that they never actually evaluated. There is a lot of talk about these blanket templates being a high risk during an audit.

Although, what I think the above quote highlights is something that I’ve seen regularly in healthcare. Many doctors are chronic under coders. I think this other quote from the article linked above explains why many doctors under code:

“If you do a cost-benefit analysis, it might be less expensive to undercode than try to deal with an investigation,” she said. But Fenton has found that there doesn’t have to be a large increase in coding levels to see a significant bump in revenue.

I’m sure there are many reasons that doctors under code, but this could be the largest one: fear. The fear of an audit uncovering over coding is real and palpable. Plus, an EHR automated E&M coding engine doesn’t solve this problem for a physician. At the end of the day the physician is still responsible for the coding, not the EHR software.

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.

2 Comments

  • In our practice we used the automated coding for about 6 months until the system trained us to code accurately on our own.

    Every once in a while I check my level of coding against the system to be sure I haven’t “drifted.”

  • I’ve heard other people talk about the automated coding in an EHR as a good system to train someone on coding. That’s interesting that you use it that way together with some common sense.

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