Doctors Fear EMRs Will Mess Up E&M Coding

Here’s one more example of technology clashing with habit. Apparently, even when EMRs are ready to code for doctors, Medicare physicians often hand-code anyway, according to the HHS Office of the Inspector General.

The OIG study, which was requested by ONC, looked at how Medicare docs use EMRs to assign and document codes for evaluation and management services. According to the study, 57 percent of Medicare physicians use an EMR, and of those, 90 percent use their systems to document E&M services.

The rub is that most of that 90 percent assign codes manually, rather than letting the system do the work, the report notes. That’s not surprising, however, given that doctors are on the hook if HHS finds fraudulent upcoding whether it’s the software’s fault or not.

How can the industry cope with this issue? I liked the suggestion made by Susan Fenton, PhD, assistant professor at the College of Health Professions at Texas State University.

In an interview with American Medical News, she argues that HHS and the Department of Justice should get together to certify coding capabilities of given EMRs.  She also recommends that the two agencies should agree that physicians not be held liable if something was coded wrong, as long as the practice didn’t alter the software.  (The American Medical Association has made similar recommendations.)

Honestly, I think the compulsion to do hand-coding goes deeper than a fear of getting slapped by the DoJ or HHS.  If you don’t feel comfortable with an EMR, you’re likely to do as much of your work as you can in “the old way.”  Heck, I know I would. But the very reasonable fear of government sanctions makes the situation much worse. Certifying bodies, start your engines.

About the author

Anne Zieger

Anne Zieger

Anne Zieger is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.


  • Pardon my ignorance, but are we referring to ICD or CPT codes? Assuming so, can’t most systems ‘suggest’ which codes to use but allow the doctor to add, delete or amend?

    You would think that if a doctor puts in the proper ‘notes’ and checks off the right boxes, that the software ought to do well in picking both types of codes. Am I wrong?

  • R Troy–yes you are wrong–Using templates and boxes is difficult at best when documenting with EHR. If I only used the templates for physical exams and history taking it would take me 20 minutes to see a simple sore throat. A physical would take over an hour JUST for the DOCUMENTATION (oddly patients prefer we actually LOOK at them instead of an electronic apparatus). EMR’s have complete lack of capability in determining complexity of thinking when evaluating a patient’s complaint. This is why EMRs need “Natural Language Processing” to help us code properly. Most docs quickly learn that they need to dictate or free text in order to properly care for their patients in a timely fashion.

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