Inpatient Facility Coding & Compliance Alert

Tip: Pay special attention to your E/M service coding for ER and clinics.

Using electronic records can be an easier way to keep track of patient information, but it can also set hospitals up for being on the CMS watchdog radar.

A recent letter from HHS secretary Kathleen Sebelius and attorney general Eric H. Holder, Jr., acknowledged that "electronic health records have the potential to save money and save lives." But the letter also stated that, "There are troubling indications that some providers are using this technology to game the system, possibly to obtain payments to which they are not entitled. False documentation of care is not just bad patient care; it’s illegal."

The letter was sent to five major hospital trade associations: the American Hospital Association, the Federation of American Hospitals, the Association of Academic Health Centers, the Association of American Medical Colleges, and the National Association of Public Hospitals and Health Systems. It cited possible abuses of electronic records, including "cloning" of medical records to inflate reimbursement.

"There are also reports that some hospitals may be using electronic health records to facilitate ‘upcoding’ of the intensity of care or severity of patients’ conditions as a means to profit with no commensurate improvement in the quality of care," the letter stated.

Focus: Regulators are concerned about increased billing for the most expensive evaluation services by hospitals, in the emergency room, and by physicians in their offices. One of the specific concerns is with upcoding hospital E/M services in the Emergency Department and/or provider-based clinics.

CMS is conducting audits to prevent improper or inaccurate billing, and is starting extensive billing practice reviews that will identify hospitals or physicians who are billing for much more expensive services than their peers.

"This letter underscores our resolve to ensure payment accuracy and to prevent and prosecute health care fraud," the letter stated. It reiterated that a patient’s medical information "must be verified individually to ensure accuracy; it cannot be cut and pasted from a different record of the patient, which risks medical errors as well as overpayments."

Reaction: The letter echoes what some experts have been advising physicians and facilities for quite some time.

"Even though CMS has not disallowed cloning or copy/paste from prior encounters, now they’re stating that it’s not allowed unless verified," says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CPC-I, CENTC, CHCC, president of CRN Healthcare Solutions in Tinton Falls, N.J. "I’ve been telling providers and EHR companies all along that whenever a note is cloned, the note should indicate that the provider reviewed the note."

Down the road: The letter also called for Medicare to establish clear national guidelines for billing hospital emergency room and clinic visits.

Resource: Read the entire letter from Sebelius and Holder posted by the New York Times at http://www.nytimes.com/interactive/2012/09/25/business/25medicare-doc.html.