Not surprisingly, the adoption of electronic health records (EHR) has been associated with higher charges, especially in the emergency room setting (NEJM 2012; 367: 2465-67).  The question remains whether this increased complexity that is being billed is justified or simply due to “gaming” the system with electronic technology.

A specific example has been the increase in the highest level 5 codes used in emergency department (ED) visits, from 27% to 48% of Medicare charges (2001 to 2010).

While “gaming” may be part of the answer, more of the answer lies in the increasing complexity of patient conditions and more complex therapeutic options.  Specifically, the increase in higher coding has been associated with the following:

• Marked increased use in new diagnostic technology. Overuse of technology is ill defined and failure to diagnose carries a much heavier penalty for physicians.
• Increased numbers of patients without medical homes.  This increases the need for more diagnostic certainty.
• Reduced hospital capacity.  Patients may be boarding in ED for quite some time before eventual admission or discharge.

Although the reasons stated explain how there may be more justification for higher complexity, it is well-recognized that EHRs facilitate billing by presenting check-boxes to more easily satisfy coding requirements.  This helps eliminate undercoding.  One of the drawbacks, though, with EHRs has been elaborate documentation at the expense of more direct patient contact.

Take home message:

The current system of coding is flawed.  While the complexity of care has increased, it remains difficult to identify the true value of the care provided. When most incentives reward increased testing and increased documentation which are easy to quantify, this is what will happen.