More isn’t always better. Electronic health records (EHR) offer advantages to improve documentation. For example, legibility is not an issue. But EHR also poses special challenges. One particular concern is office visit upcoding or inflation because of a surplus of useless or irrelevant data that enlarges the medical record and creates note bloat — the medical version of the dreaded “TMI” (too much information). The Office of Inspector General (OIG) of the Department of Health and Human Services reported on the phenomenon of code creep in a study that examined evaluation and management coding over a 10-year period (Figure 1).¹ Over time, the proportion of high-level evaluation and management (E/M) codes grows as lower level codes are used less frequently. EHR potentiates note bloat, resulting in code creep by making it easy to copy and paste large amounts of data into a medical record. Also, the volume of notes within EHR expands when you check boxes that append default phrases such as “normal conjunctiva” or “clear cornea.” Here are some tips for preventing this problematic byproduct of EHR.

THE ROOT OF CODE INFLATION

Because CPT coding for office visits heavily relies on counting elements within the medical history and examination, and more elements implies a higher level of service, there is an economic bias in favor of more expansive notes. When the artificial intelligence of a coding engine counts these elements and recommends a procedure code, the result is code inflation. These coding engines generally ignore eye codes (920xx) and concentrate on E/M codes (992xx). The engines also find it difficult or impossible to assess the gravity of the disease(s) and the intensity of the associated treatment(s), which account for the level of medical decision making (MDM). The definitions of E/M services in the CPT manual that hark back to the 1995 and 1997 E/M Documentation Guidelines are the primary reference point for determining the level of service, and coding engines exploit the heavy dependence on enumerating elements. A key selling point of EHR systems is the ease of populating fields in the medical record and the subsequent increase in the level of service.

EMPHASIS ON MEDIAL NECESSITY

While the E/M guidelines place the office visit elements, history, exam, and MDM on par with one another, Medicare’s Claims Processing Manual instructions subordinate the history and exam to MDM.²

“Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed.”

CGS, a Medicare Administrative Contractor, notes in its fact sheet for coding established patient visits:³ “Medicare allows only the medically necessary portion of the visit. Even if a complete note is generated, only the necessary services for the condition of the patient at the time of the visit can be considered in determining the level of an E/M code.” It also notes, “…medical necessity is ALWAYS the overarching criterion” [emphasis in the original].

Redundant or noncontributory chart notes should be ignored in selecting a level of service consistent with medical necessity. For example, repeat exams at short intervals for a chronic condition such as macular degeneration cannot all be comprehensive, since the 12 elements of the exam are not all pertinent to the assessment and management of the posterior segment disease — specifically, ocular muscle motility and eyelids have no bearing. The notion of a dozen or more serial comprehensive exams points out the considerable flaw in coding a single exam without considering the context of prior exams. Coding engines are not designed to look at the previous pattern of office visits as another factor in weighing MDM and consequently are vulnerable to upcoding.

This issue is magnified in group practices where anterior segment and posterior segment physicians treat a single patient with multiple ophthalmic diseases such as AMD, glaucoma, and cataract. The tendency of each physician is to select the level of service that reflects only those eye exams that he or she performed and to ignore the notes of colleagues in the same medical record. This perspective overlooks the value of collaboration and gives little or no credit to the observations of colleagues, as if they are unreliable.

For instance, a prior chart note contains a detailed evaluation of the intraocular pressure (IOP), anterior chamber angle (ACA), and optic nerve (ON) for chronic open-angle glaucoma (COAG) by a glaucoma specialist, and the subsequent exam 2 weeks later contains another set of similar notations for the same exam elements by the retina specialist as well as notes about the fovea, macula, vitreous, and peripheral retina. Does a repeat IOP, ACA, and ON count toward the level of service for the exam by the retina specialist? Probably not, because it is a repetitive note that does not contribute to the management of AMD and a 2-week interval is too short to see any appreciable change in COAG absent some extraordinary occurrence such as ocular trauma. The same point can be made for repeating family and social history on sequential exams when there is nothing new.

CONCLUSION

A blizzard of information in the medical record does not necessarily represent useful notes — it confuses the physician and hides the salient information. The best medical records are accurate and describe the evaluation and management of the presenting condition(s). Not every patient encounter requires a comprehensive history and exam, and extraneous notes are of little value. Insufficient training of technicians and scribes can lead to superfluous notes and inefficiency. Always consider MDM as the critical factor in determining the level of service and you can be confident in your code selection, even when the history and exam are bloated within your EMR. More is not necessarily better when it comes to charting and coding. RP

REFERENCES

1. Office of Inspector General, Department of Health and Human Services. Coding Trends of Medicare E/M Services. May 2012. https://oig.hhs.gov/oei/reports/oei-04-10-00180.pdf . Accessed March 26, 2017.
2. MCPM Chapter 12, §30.6.1.A – Selection of Level of Evaluation and Management Service, Use of CPT Codes.
3. CGS Administrative Contractors, LLC, Fact Sheet, CPT Code 99215. https://www.cgsmedicare.com/partb/mr/PDF/99215.pdf . Accessed April 23, 2017.