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If you submit too many level 4s, you could be audited.
A few years ago, auditors from HealthAmerica, a unit of Coventry Health Care, visited a seven-doctor family practice in Pittsburgh. Since the group had implemented its EHR, the physicians had been submitting an increased number of level 4 codes, and the plan had decided to make an example of them, recount family physicians Joel N. Diamond and William A. Fera III, who were then members of the group. Not only had HealthAmerica withheld about $20,000 in payments due them over the previous two months, but it had also threatened to take back more money if they'd done anything wrong.
Fortunately, the auditors found nothing amiss. "In every chart they went through, they saw that the charges were legitimate level 4s," recalls Diamond. "Out of frustration, they said maybe some of the charts weren't in the spirit of a level 4. We argued that we weren't sure what the 'spirit' guidelines were in the E&M coding booklet. They went away with their tail between their legs, and we felt vindicated."
HealthAmerica, which did not respond to a request for comment, is not the only plan auditing practices that have EHRs. Around the country, "a lot of doctors have been audited," says Mark Anderson, a health IT consultant based in Montgomery, TX. "So far, they're all matching the [CPT] requirements on the good EHRs." Not all EHR code checkers, he adds, examine documentation properly to make sure that a particular code level is warranted.
If a plan audited a physician with an EHR, it could tell whether the doctor was upcoding even if his documentation matched up, says Bruce Kleaveland, a health IT consultant who, until recently, was chief operating officer of Practice Partner, a Seattle-based software company. What the auditors would look for, he says, is "a pattern of generic notes. They'd say, 'Dear Doctor, you've got the same note here, and there's no meaningful clinical observation. You're just cutting and pasting and sticking it to us.' "
What the software vendors are really worried about, however, is that plan audits will scare physicians away from EHRs. Diamond and Fera, who speak about health IT across the country, say they've gotten a number of questions about this from physicians.
But in the long run, says Kleaveland, none of this will stop the spread of EHRs. "It might slow it down. But there are larger forces in play that are going to make it part of how doctors do business."