Education is Not Enough: CMS Needs to Change the Coding Requirements

by Ivy Baer, J.D., M.P.H. , Senior Director and Regulatory Counsel, Regulatory and Policy Group, Association of American Medical Colleges

The article by Agrawal and others discusses program integrity issues, beginning with several egregious—though hardly typical—examples of schemes that have been used to commit fraud on the Medicare program.  The authors acknowledge that “the vast majority of physicians, suppliers, and providers are honest and do not seek to defraud or abuse public or private programs,” but note that audits have revealed that many services are incorrectly coded and may lead to incorrect payment by Medicare.  As Dr. Lyles demonstrates in his commentary, a well-designed education program is an important tool for improving coding.

However, the premise behind the Agrawal article is that education is the solution.  This fails to address the bigger problem with coding requirements, which is that most of them were written in the last century and do not reflect the way medicine is practiced in the 21st century. For example, under the current coding requirements for evaluation and management services, developed in 1995 and 1997, each note must include information that is generally stagnant (or stable) and viewable/updateable elsewhere in the electronic health record (EHR).  This clutters the note and detracts from the assessment/plan documentation which reflects the clinical judgment and treatment plan of the physician. The Centers for Medicare and Medicaid Services’ (CMS) rules should recognize that EHRs store prior information, which can be marked as reviewed or updated as needed.  To repeat this information in the body of the encounter note for the sole purpose of E/M documentation and billing renders the note less useful for quality patient care.  As with many Medicare requirements, these two E/M Guidelines should be revised and modernized in recognition of EHR technology; reduce burden on providers; and increase the accuracy—and therefore the usefulness—of data entered in the electronic health record, thus supporting the provision of quality care and allowing for population health management.

A new documentation system should incorporate the current realities of medical practice, including at a minimum current patient care standards (with sufficient flexibility to be changed rapidly as improvements are disseminated throughout the system), care delivery by teams, and the ready availability of information about each patient that is a click away in the EHR.  Coupled with these changes should be educational efforts aimed at the entire care team.

Good documentation supports good patient care while simultaneously providing all payers with the assurance that patients are receiving medically necessary care that meets established quality standards. Dr. Agrawal is right that most providers are honest.  CMS could do them a great service if it would commit to working in partnership to develop a new documentation system.

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One Comment

  1. Kemi Tomobi
    July 16, 2013 at 10:18 PM

    Education is key, therefore I agree with Agrawal.  How one is trained determines how one practices.  If coding does not reflect the way physicians need to practice in the 21st century, then doctors need to be trained in order to know what services to order and to do no harm to the patient.  After all, doctors have to abide by this oath. 

    An article published in JAMA this month by Moriates et al, “First, do no harm” stresses the need for doctors to know what tests to order and what is financially necessary so that doctors do not financially harm the patient.  Perhaps improvement in coding and recordkeeping can allow for more individualized care, screening for financial risk, and avoidance of unnecessary tests.


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