Medical Billing Blog

The Office of the National Coordinator for Health Information Technology (ONCHIT) will soon release a description of the “meaningful use” of electronic medical records (EMR). Until HHS releases what it will require for a EHR user to receive the EHR stimulus money, then it’s anybody’s guess just what the heck meaningful use of an EHR actually means, please forgive the pun

I can think of a number of factors that may or may not be part of this aspect of the standard:

• The number of years the practice has used the system within the practice.  Part of the way the money is being passed out is to encourage early adopters, they actual get a bigger incentive to convert to an EMR.
• Does the data on the system get passed to other systems.  In other words, is the data transparent and can other systems export and import the demographic and clinical information.  A simple example is placing a lab test and recieving the results back into the EMR.
• Does the system improve the quality of care.  Well duh, but I bet this is the hardest part to quantify but isn’t this the most important factor.

But as I’ve read the healthcare blogs I’ve seen another thought about meaningful use.  The concept evolves around that concept that “meaningful use” should somehow measure if the user(s) is/are move effective in their practive of medicine with the system.  From a productivity vantage key to measure this would be great but even more difficult to define.

In today’s ModernHealthcare.com there’s an article on EMR Usablity and CCHIT Evaluation.  The main point is simple, make the user friendly aspect of an EMR part of the certification process.   I am in total agreement, most EMR may pass the “mechanical” aspects of interoperability but are hard to use.

The stimulus act ignores the brutal  fact that traditional EHR systems will NOT solve much of the healthcare industry’s woes if doctors can’t or won’t use them. The incentives assume that “if you fund it they will come” this just isn’t the case.   I love this remark in the article “Based on the “success” of EHR systems over the past 10 years, this bet could be akin to AIG’s bets on credit default swaps.”

Here’s the problem with usability, much of this is in the eyes of the beholder.  Its not just a matter of how many clicks a task takes.  I agree with the sentiment of the author but this is a very subjective issue, classic apples and oranges.

Google Health is going to fail, it’s that simple. Actually since it will be in perpetual beta no one will notice.

It’s going to fail for the same reason that all PHRs are going to fail. You can’t design a system when you don’t have process and policy in place. In the US health market you have neither.

Right now we have the classic general system design philosophy being practiced. “If you don’t like the facts, get rid of them” Whether its Google Health, AllScripts, or Revolution Health its all a bunch of arrogant tech money trying to make more tech money, won’t work.

Neither the doctor nor the patient are truly at the center of any of these efforts.

Neither are most of the real stakeholders, a very long list.

Do I have a better idea, sure, who doesn’t. The question is how long will it take before the right people come to the table, some time. So in the meantime thanks for the betas, we’re all watching and learning.

Most Primary Care Physicians are more then familiar with CPT coding, or the Current Procedural Terminology (CPT) code set which is maintained by the American Medical Association.

These codes, mostly 5 digit numbers, represent the procedures that doctors, and other practitioners perform. These codes and are the basis on which payments from insurance and the Medicare are made.

This arcane system is normally reduced to a simple nomenclature based on the last digit in the CPT code. For example the CPT codes for new patient in-office visit are:

• 99201
• 99202
• 99203
• 99204
• 99205

These numbers go from 1 to 5 so they are normally referred to a Level number exam. The higher the number the more complete the examination will be. Healthcare professional will use the verbal shortcut and say “It’s a Level 3 exam”

But let’s look at what happens when its time to get paid for these services. The insurance carriers gather E&M codes on a per practice basis. They gather these statistics and then they establish ratios that they expect a doctor to maintenance for the higher coded exams. This is quota system, nothing more and nothing less.

It is not usual to our staff to establish a solid working relationship with their counterparts at the insurance company. As a large processor of claims we will often be given “advice” when a physician is getting too near the “quota” for the higher level exams.

What does this means? It means that a PCP has to be concerned with towing the carriers’ line or expect a request for further documentation or even an audit.

The Journal of the American Board of Family Medicine study, Accuracy of CPT Evaluation and Management Coding by Family Physicians study done in 2001 was quite through but came to the wrong conclusions. Physician under-code old patients because they are afraid that they will be punished for spending too much time on each patient, which is what the higher level codes actually represents.

Further, they “over-code” new patients because the higher codes are extremely restrictive. The Evaluation and Management Services Guide issued by the The Centers for Medicare & Medicaid Services (CMS) is a confusing document. Even the AMA’s CPT coding book has a section towards its back that tries to breakdown the different levels and explain them in plain English with specific examples.

Correct coding will decrease claims denials and speed up payments, as a billing company that’s what Preferred Health assists our practices to do. But if CMS and the major carriers want to move towards preventive medicine they need to move away form intimidation by CPT code.