Andre S. Chen, MD, MBA is the developer of STAT E&M Coder for the Palm OS
The most intriguing handheld applications are the ones that create solutions, tailored specifically for handheld use, which heretofore had not existed for the PC platform. One example is the current interest in handheld prescription writing software. Other examples of unique handheld solutions are applications that facilitate Evaluation and Management (E&M) coding. This new type of application attempts to automate, for the clinician, the complex documentation process that that government and private insurers require to justify claims for a particular level of service. E&M codes are an issue for just about any practicing physician.
Some examples of recent E&M coding issues:- A national managed care insurance company institutes a coding initiative in Florida and Texas auditing all of the Level 4 and 5 services of a select group of physicians. The millions of dollars saved in lower payments prompts the company to expand the program nationally within several weeks. ( Controversy greets Humana's claims review program - American Medical News)
- A major university hospital agrees, in federal court, to a $10.9 million dollar settlement with the federal government involving "upcoding" of physician services to cancer patients under the Medicare and Medicaid program.
- A civil complaint filed by the federal government seeks as much as $37 million dollars from a single primary care physician, alleging inappropriate use of Level 4 and 5 office visit codes over several years. Under the False Claims Act, the government can recover up to $10,000 per false claim proven at trial. ( Feds try new tack in charging doctor with upcoding - American Medical News).
These are just a few high profile examples of the fastest growing reimbursement battle between doctors and insurers. E&M services, which all physicians provide to some extent, involve cognitive services such as office visits, consultations, and hospital-based care. There are generally five levels of service that a clinician can choose to bill based on the amount of time, complexity, and risk involved in providing the service. The guidelines for these levels have, traditionally, been very subjective, with terms like "straightforward" and "complex" used to describe the components.
In 1995 and 1997, the Health Care Financing Administration (HCFA) in conjunction with the American Medical Association (AMA) sought to further define these guidelines in an attempt to make their use more uniform ( HCFA Documentation Guidelines for Evaluation and Management Services). However, the complex algorithms in the 1997 guidelines prompted a national outcry among physicians and the guidelines were made optional pending further work ( Fiercely debated E&M coding guidelines face field testing - American Medical News).
One of the main complaints among physicians is that the guidelines are complex and require the clinician to count up various elements of the History of Present Illness, Review of Systems, and Exam. Physicians don't want to navigate complex algorithms simply to decide whether a visit is a Level 3 or Level 4. Counting documentation elements particularly irritates physicians as an unreasonable hassle. However, HCFA has insisted on maintaining these features as a way of making documentation guidelines unambiguous in order to detect and mitigate upcoding, or billing for a higher level of service than is appropriate.
E&M coding tools are the electronic equivalent of paper-based templates or checklists that many physicians use to ensure compliance with the established guidelines. Clinicians typically use these tools as they dictate their notes, checking off the relevant documentation elements as they go. More complex sections such as Medical Decision Making are reduced to their component parts of Diagnoses, Data Review, and Risk. The software tools, however, do the counting, navigate the algorithms, and change the templates based on the type of visit being documented. For example, there are currently ten organ-specific examinations available.
Clinicians who are already familiar with E&M coding guidelines find data entry quite rapid even as beginners. Others must slow down some to learn the individual documentation elements and other available choices. Eventually, most users report that documentation becomes much more rapid and efficient, especially as one develops a sense of the algorithms obviating the need to use the software each time.
Handheld E&M coding tools:
- Automatically count the documented elements;
- Automate the navigation of the coding algorithms;
- Prompt the user to dictate relevant documentation elements that may otherwise be omitted;
- Enhance the efficiency of documentation by focusing attention on "relevant" documentation elements;
- Teach clinicians the documentation guidelines by providing real time feedback;
- Ensure virtually 100% accurate E&M coding;
- Allow the use of any of the organ-specific examinations by any clinician;
- Are ultra-portable and can be used in any setting that a clinician dictates their notes;
- Do not rely on controversial boiler-plate templates or checklists;
- Are transparent to the reader or auditor of documentation;
Clearly, many clinicians choose to ignore E&M coding issues, leaving them vulnerable to compliance actions and aggressive discounting by insurance companies. Others choose to purposefully downcode their services, saving payers even the effort required to perform audits. It is quite surprising, then, that only a few choose to: 1) thoroughly learn the current rules of engagement and 2) arm themselves with the tools necessary to prevail. Most probably need to look no further than palm of their hand.