The HITECH Act has substantially influenced the adoption rate of electronic health records (EHRs). According to several recent sources, EHR users now outnumber those who continue to manage patients within a paper-based office chart. Recently the Office of the Inspector General (OIG) generated a report that not only validated this trend, but also provided another interesting tidbit regarding coding a note. According to the OIG the vast majority of providers manually code the note, choosing not to use the coding engines available in almost every EHR.
Of interest, this report from the OIG was created in response to a request from ONC. ONC made the request because they were not only interested in the level of adoption of certified EHRs, but also the extent to which the EHR was being utilized to capture evaluation and management (E/M) services. Within the context of a nephrology practice’s utilization of an EHR, E/M services basically refer to office-based patient visits. Those are typically conveyed to CMS from a claims perspective by submitting one of a handful of CPT codes: 99201-05 for patients new to the provider and 99211-15 for follow-up patients.
Who did the OIG ask?
The basis for this report was an electronic survey of 2,000 randomly selected Medicare providers. This represents a tiny fraction of the almost 442,000 providers who submitted at least 100 E/M services in 2010. This small sample explains some of the resulting wide variations in the detail presented within the report. The survey was conducted between October 2011 and January 2012 and the response rate was roughly 75%.
What did they find?
The report contains a number of interesting findings:
- 57% of Medicare providers used an EHR at their primary office location in 2011
- 73% of those using an EHR were using an ONC-ATCB certified EHR (meaningful-use ready)
- 90% of those using an EHR were using it to document E/M services
- 88% of this group assigned E/M codes manually in 2011
What does it mean for nephrology?
The OIG appropriately points out the greatest limitation of this report is the findings are based on self-reported data from Medicare physicians. Combined with the small sample size, the confidence intervals established by the report are wide. The report sampled all providers regardless of specialty. A quick “back of the envelope” calculation suggests to me they may have included 10-20 nephrologists in this survey.
Nonetheless, the 57% adoption rate is almost identical to the 2011 figure observed in a recent CDC survey. The surprising finding to many will be the remarkably low utilization of built-in E/M coding tools. When EHRs enter today’s competitive market, meaningful use certification and E/M coding are expected to be present. E/M coding engines are based on AMA-coding guidelines. Although these guidelines have been around for 15 years, their interpretation from an audit perspective is not black and white. In the absence of advanced natural-language processing, E/M coding today requires cumbersome templates, the output of which many providers are not willing to send to a referring physician.
To code or not to code is actually not the question. In my view providers will be compelled to code for the foreseeable future. The real question is, Will EHR vendors create a coding solution that couples usability with an elegant output? Within a competitive marketplace, that will almost certainly happen. What are your thoughts about the OIG report? Add your comments and join the conversation.