HHS auditors target upcoding of Medicare bills via EHRs

The Obama administration is conducting targeted audits of hospitals to find possible upcoding of medical services related to use of electronic health records.

Don White, a spokesman for the HHS Office of the Inspector General, said the OIG is conducting audits of “specific institutions” on EHR-related overbilling.

Concerns that hospitals have padded their Medicare bills by using the detailed coding ability of electronic health records arose from reports that payments have surged to some hospitals as they implemented EHRs. In September, HHS Secretary Kathleen Sebelius and Attorney General Eric Holder echoed those concerns when they wrote to hospital groups warning against EHR-related upcoding.

In response, CMS Administrator Marilyn Tavenner said at the March meeting of the Federation of American Hospitals that her agency would undertake targeted audits focused on EHR-related upcoding. That was followed by a May 3 “listening session” hosted by the CMS and the Office for the National Coordinator of Health IT to discuss the increased billing that has occurred in some hospital codes.

Additionally, a proposed Medicare payment rule for hospital outpatient services in July included a proposal to replace five levels of outpatient visit codes as part of an effort to reduce upcoding. Instead, the agency proposed a single Healthcare Common Procedure Coding System code for each unique type of outpatient hospital visit.

This week, an HHS official speaking on condition of anonymity said the targeted audits will continue and that the CMS is considering other steps. A CMS spokeswoman would not comment on either issue.

The actions appear to have mollified concerns on Capitol Hill, because the upcoding issue did not even come up a July 17 Senate Finance Committee hearing on the status of the EHR incentive program that covered a range of problems associated with the initiative. That is a big change from earlier congressional reactions to the issue, which included calls late last year by House Republican leaders for suspension of the EHR incentive issue until the threat of upcoding is resolved.

Look for the issue to possibly come up again through the OIG's office, which added inappropriate Medicare payments related to EHR use to its fiscal 2013 work plan. The OIG's office said “Medicare contractors have noted an increased frequency of medical records with identical documentation across services.”

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