Feds Claim Hospitals Are Using EMRs For Upcoding

Geez, you can’t win for losing these days. First the feds put enormous pressure on hospitals to near-bankrupt themselves buying sophisticated EMRs and meet Meaningful Use standards.  Now, as a piece in The New York Times notes, the feds are going after hospitals which are allegedly using EMRs to upcode Medicare and Medicaid claims.

As my colleague John notes, the key finding that The New York Times article discusses is that Medicare costs have gone up substantially for those using an EHR. This has the feds’ knickers in a twist. The administration now plans to look aggressively for providers who are committing coding fraud, while also considering whether it needs to change the way it pays for care.

In a letter signed by U.S. Attorney General Eric Holder Jr. and HHS secretary Kathleen Sebelius, the Obama administration said that their are “troubling indications” of abuse in how hospitals are using EMRs to bill for services.

The letter, which went out to five major hospital trade associations, warned that it was aware of abuses such as “cloning” of medical records — in which information on one patient is repeated in other records to inflate reimbursement. CMS has also gotten reports that hospitals are upcoding the intensity of care or severity of a patient’s condition.

The American Hospital Association, for its part, says the problem is partly on CMS’s own shoulders. As it noted in a letter responding to the administration, hospitals have been using CPT and E/M codes to report utilization at clinics and emergency departments.  The AHA has asked CMS to implement a set of national hospital E/M visits developed by an independent expert panel, but to date, CMS has neither implemented those guidelines nor proposed its own, the association says.

You know what? I think the AHA has a very good point. Unless CMS issues a single national standard for reporting such visits, coding is going to all over the place. That’s just reality.

Meanwhile, as to whether hospitals are trying to put the squeeze on CMS by fraudulently upcoding, it’s anyone’s guess, but my theory is that hospitals are merely doing a better job of capturing what they’re already doing . So while I appreciate the need for CMS to be vigilant, they might want to do some studies before they accuse hospitals of criminal misbehavior.

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.


  • Anne,
    Couldn’t agree more with the AHA letter to AG and CMS that a national standard needs to be set and vetted by experts. That way, each hospital ED doesn’t bear the burden of creating their own leveling system. This is a long-standing issue that needs to be addressed.

    Another reason for the problem is the EHRs’ ability to auto-code cases based solely on the physician’s mouse clicks. Click-happy physicians tend to over document within EHR documentation templates, creating an overabundance of codes behind-the-scenes. Easier to click than write. It is an unintended consequence of the EHR.

    Only through proper set up of EHR documentation templates and automatic code assignment can this problem be controlled. Having human eyes take a look at codes prior to bill submission is also important, especially if billing problems and denials are an issue. And finally, better physician documentation training from the get-go.

  • I remember back when my son was born reading through the hospital bill several weeks later. Among the surprises was a charge for something – test, med, I can’t remember, but I do remember that it was dated about a week before he was born! Hey – you don’t need EMRs to ‘upbill’! I’ve seen numerous excess charges in medical and hospital bills over the years – including tests and treatment that I never received but insurance was billed for – and which inflated my coinsurance.

    Maybe having better documentation allows for some more codes to be submitted. But I’ve long noticed that insurance companies are quite adept at finding overlapping diag and treatment codes and avoiding overpayment; I can’t believe that CMS contractors can’t do that too. What neither can do is readily spot fraud – as long as it looks reasonable for a listed treatment to have been done, but if it looks like a treatment is excessive it can and may well be challenged. Do standards need to be revised and extended because of EHR’s? Probably too soon to tell.

  • Upcoding frequently rears its head in the coding world. Sometimes founded and sometimes not. Interesting that upcoding is being linked to EMRs.

    There are so many factors to coding from an EMR that one would expect to see a benefit from the technology. This benefit is not necessarily fraudulent. It just maybe the result of a better process.

    In the end, it all comes back to the accuracy of the physician documentation and how critical that documentation is to the coding of the entire case.

Click here to post a comment