Could EHR be to blame for the trends in "Upcoding?"

**Jubilee** · 03-12-2013, 08:18 AM

Reading some of the latest articles around the health care crisis, one fact that has continually been mentioned is the trend for "upcoding" in the past few years. Upcoding is the term to describe how many visits that once were considered level 1 or II visits, are now routinely being billed for higher levels/complexity visits.

Yesterday when I was talking to the Clinical Director of a fairly large ophthalmology group, she mentioned how they haven't found an EHR they liked. One of the biggest complaints that they had was almost every EHR suite they tried forced them to jump through the "hoops" in a certain order before getting to the screen they wanted. You always had to review the history. It always wanted presenting VAs, Habitual Rx, Etc. So even if you were bringing someone in for a simple pressure check, the EHR was forcing you to do a more "complex" exam. So of course, if you did the extra steps, you should be paid for it. Your EHR will automatically put in the code on the insurance form.

So could it be possible that the push for EHR in some ways is driving that trend?

**drk** · 03-12-2013, 08:34 AM

EHR companies have to make a living. Of course they are going to sell software that helps you get paid. That's their job.

Any practice can jump around as much as they want in their software. "Upcoding" is on the practice, not the software.

What's more, there is a limit to what a payor will pay based on medical decision making, the type of diagnosis, etc. It's not all about the procedures.

Good point, otherwise.

**Jubilee** · 03-12-2013, 11:50 AM

Which were some of the points we were talking about. Yes, most practices want an EHR that will assist with coding. Being able to get every dollar you are entitled to is what most practices want. However, for those who struggle with coding advice, or more apt to accept the EHRs recommendation, then that does result in a lot more level 3,4,and 5 visits, compared to 1 and 2.

While most "vision plans" will only cover 1 comprehensive exam a year, health plans that deal with vision related disorders may cover multiple E&M visits of varying complexity. Of course, part of that is based upon diagnosis code, but there are many reason why someone would need several complex visits.

My thought was just along the lines of how it affects all types of clinics. The current trend/mode of thought is that more dollars are saved through wellness and preventative care than treating disease once it has already manifested itself. This is why most plans now have coverage for smoking cessation, routine screenings, physicals, etc. Even more so, many plans are paying doctors bonuses for making sure their patients are getting their routine services so they can hopefully nip things in the bud. A lot of that has to do with wanting to be a 4 or 5 star plan in the eyes of the CMS which will help them get more lives, etc.

I just thought it was an interesting take away. Something that perhaps in our continuing health care discussions/reform should think about.