No upcoding caused by EHRs – yet, study finds

For every technology, there's a downside—and for EHRs, one of the buzzed-about downsides was the supposed ease of upcoding: the practice of selecting the most remunerative code for a particular procedure. But a new study in Health Affairs—published by Julia Adler-Milstein of the University of Michigan and Dr. Ashish K. Jha, an internist with the Veterans Affairs Department and professor with the Harvard School of Public Health—casts doubt on that preconception.

The authors used a case-mix index to measure the weight of its codes and, thereby, the extent to which a hospital may be upcoding. The authors then matched early adopters of EHRs, from 2008 to 2012, to hospitals (up to three) that were similar in all other respects. The latter group served as a control.

The authors concluded that the two groups were indistinguishable, with both increasing the weight of their codes nearly identically. And the results held for several subgroups: for-profit hospitals; hospitals in the most competitive markets; and hospitals with the highest proportions of Medicare admissions.

Jha, in an interview, said that Adler-Milstein's theory from the start was “that hospitals have invested so much on coding” that they wouldn't wait for use of EHR to maximize coding.

Jha, on the other hand, took initial reports of upcoding at face value. “And I was wrong,” he said. “This (study) should offer everyone a little bit of reassurance, that we have not created this one, very important, potentially financially significant, unintended consequence. I think everyone has been worried about this.”

Still, he warns, “We need to track this—I don't think this issue needs to be settled and done,” in response to suggestions that technology might change and enhance providers' ability to upcode. “But as long as we monitor this closely, it shouldn't be an issue.”

The theory that use of EHRs could encourage upcoding dates back, in part, to a September 2012 report from the New York Times, was that the technology allows doctors to copy-and-paste documentation from one encounter to another to generate fraudulent claims or uses artificial intelligence to ensure the most intensive code for a given procedure. Analyzing data between 2006 and 2010, the article postulated that hospitals receiving meaningful-use payments had a 47% rise in Medicare payments at higher levels of coding, versus a 32% rise in hospitals that hadn't received payments.

The alarm raised by the story was matched by the Office of the Inspector General for HHS. In a January 2014 report, the office revealed the results of a questionnaire it had disseminated among Medicare's contractors: it found few efforts to police or oversee potential fraud enabled by EHR systems. Only four of the 18 contractors conducted additional review, and only three used the EHR's audit log feature. Comparatively greater numbers said they were able to detect copied language or overdocumentation enabled by EHRs, though greater numbers of contractors claimed to be able to detect their presence in traditional paper medical records too. And, the office concluded, the CMS had not generally provided guidance on overdocumentation and copied language.

Follow Darius Tahir on Twitter: @dariustahir