EHRs and Coding

Even though it’s becoming the norm across the industry, there are still some challenges when it comes to electronic health records. Many systems have software to help providers figure out the best evaluation and management codes, and when used properly, can support accurate coding founded on medical necessity. In addition, when these codes are used correctly, they have been linked with higher levels of E/M coding.

In some cases, however, there are some software glitches. When combined with a lack of user knowledge, this can generate significant coding problems. The Office of the Inspector General has expressed concerns about electronic health records (EHRs) “aiding” in the process of providers selecting codes. To date, there has not been much testing about how well this works in practice and how the possible downfalls could be measured. What research is out there indicates that there are still some challenges ahead.

E/M Level Discrepancies after EHR Evaluation

Recent studies indicated that EHRs have features that support accurate E/M coding but all also had pitfalls that could lead to inaccurate coding. In many healthcare facilities, the responsibility for selecting the code falls on the physician. This also means that the liability in selecting the wrong code falls on the shoulders of that provider. Failing to select the right code could lead to a wide variety of problems like rejections, fraud charges, denials, and even penalties.

• One of the biggest issues found in past studies was an inability for an EHR system to identify the critical data elements that are linked to complex decision making in healthcare. This means that there could be major bugs with how EHR systems are collecting information and using it in the overall process.

The Biggest Issues Identified in EHRs

Several common issues were identified throughout electronic health record systems.

• Usability Issues: Selecting the right codes was a user challenge. Likewise, highly complex software programs made it difficult for the end user to understand how E/M coding information was being stored and how it could be changed.
• Programming Errors: In previous studies, electronic health record systems have shown improper levels of service calculation drawn from information documented in the record and misleading representation of coding-related terminology. This made it difficult for the right information from the record to be captured and could lead to denials.
• Education and Training Challenges: In many healthcare facilities, there have been inadequate staff training opportunities to date, especially when it came to the particular features of the EHR system in use. Additionally, staff showed unfamiliarity with E/M coding guidelines and indicated a lack of documentation about how specific systems determined E/M codes.
• Missing design features in the software: Multiple challenges were detected in this realm, including discrepancies in E/M code determination, inability to recognize key medical history elements, deficiencies in diagnoses, the inability to recognize documentation record conflicts, and problems with how the three levels of history, exam, and complexity were used to select the final E/M code.

Recommendations For Problem-Solving

Although there are challenges associated with the adoption of EHR systems, there is also a great deal of potential for these programs to improve patient care and make patient management easier for the staff working in healthcare facilities. When used appropriately, these systems can be very effective for coding, but staff must understand how these programs operate and how they can assist in making the program run as smoothly as possible.

• Staff must be able to understand the basic workings of the software system in use, as well as any potential bugs that could make coding errors occur more often.
• User documentation should be reviewed across healthcare facilities to better understand how E/M coding works. Coding modules and default settings should also be reviewed with all individuals who will be regularly interacting with the software program.
• Basic elements of E/M coding should be explored and explained with all staff members. It’s critical that staff members understand what data elements in the history, physical exam, plan of record, and assessment are used to select the final code. When staff are more familiar with the key elements used in that equation, they will better understand the importance of what goes into the record.
• Programs at each healthcare facility should be used to identify areas of deficiency. While there is great potential with these programs, staff should also be aware of current challenges as well as future possible problems that could occur. When staff are well versed in how to troubleshoot basic issues, the chances of inaccurate codes being used is greatly reduced.
• Education falls at the foundation of what should be used to allow staff the opportunity to understand the programs in use. When staff is more familiar with the background workings of these programs and has the chance to work through challenges as a team, coding will be improved and problems will be identified more quickly.