OIG: Docs using EHRs still manually code evaluation and management services

Most physicians who use electronic health record systems use them to code evaluation and management (E/M) services. However, they aren't bothering with the automatic coding feature in their EHR  to do so, according to a report released June 21 by the U.S. Department of Health & Human Services' Office of Inspector General.

The report, which reviewed a random sample of 2,000 physicians who bill Medicare for E/M services, found that while 90 percent of those who used an EHR to bill Medicare for E/M services, none of them used their EHR system's automatic coding modules to assign codes to the services. Almost all of them (88 percent) assigned the codes manually; the remaining 12 percent had staff manually assign codes to the services.

The OIG also found that 57 percent of the physicians sampled use an EHR at their primary practice in 2011. Of those, the largest percentage (22 percent) began using the technology to document E/M services in 2011, the year that the EHR incentive program was launched.

The report was conducted at the request of the Office of the National Coordinator for Health IT (ONC) as part of a related evaluation of documentation vulnerabilities of E/M services involving EHRs. That report will be issued separately, according to the OIG.

The OIG noted that ONC has yet to establish standards for how physicians should use EHRs to create medical records that meet CMS documentation requests for E/M services.

"Subsequent evaluations will determine the appropriateness of Medicare payments for E/M services and the extent of documentation vulnerabilities of E/M services using EHR systems," the report said.

The OIG historically has reviewed how physicians bill for E/M services to determine their accuracy, and to ferret out fraud and abuse in the Medicare and Medicaid Programs. In its 2012 work plan, for the first time, the OIG indicated that it would investigate billing fraud vulnerabilities related to EHR systems.

To learn more:
- here's the report (.pdf)
- read the OIG's report on E/M services and fraud (.pdf)
- check out the work plan (.pdf)