Good afternoon everyone and many thanks for the invitation
to speak today on a central issue of billing and coding with electronic
health records. Let me tell you a little about AAHC. We represent
nearly a hundred academic health centers nationwide and we're dedicated
to improving the nations' health and wellbeing by mobilizing and
enhancing the strengths and resources of the academic health center
enterprise in health professions education, biomedical and clinical
research, and patient care through their associated hospitals and health
systems. We have the privilege of not being discipline specific in that
we represent all the components of the academic health center, including
all the multiple schools such as medicine, nursing, pharmacy, allied
health, veterinary medicine, whatever happens to be on a particular
campus. I want to talk about the billing and coding situation at a very
high level today. Really only have three points that I would like to
make. First and perhaps most importantly we believe that the
fundamental problem in this area is that many of the billing and coding
regulations are rooted in the past. What is needed in our view is a
system of regulations that matches both the current and the evolving
environment. So we see a real disconnect there that's a fundamental
challenge and very much a fundamental problem. I will also address the
need for increased clarity, and I think you've probably heard about this
during the course of the day, in coding guidelines particularly in
inpatient settings for evaluation and management services or E and M.
And finally, I would just like to point out the significant ongoing
investment that the nations' academic health centers have made and are
making in their compliance programs. I think we all agree that
electronic health records clearly have great potential to increase
patient safety, quality of care, and efficiency. And I don't think
anyone would necessarily argue that. And they're crucial to enable
health professionals to deliver patient care, especially I think the
patient care of the future. But changing demographics, increased
coverage due to the Affordable Care Act, and evolving payment models and
clinical experiments along with a myriad of technological advances, are
all contributing to a time of what we would describe as a time of
disruptive innovation in the way health care is delivered. To meet the
needs of their patients health professionals will need to be able to for
example to work effectively in interdisciplinary and inter-professional
teams, practice at the very top of their scopes and capabilities, and in
doing all this work seamlessly with electronic health records and other
available technological tools. AAHC and its member institutions
acknowledge that while electronic health records offer great opportunity
they certainly pose potential problems. You know we were one of a
handful of organizations that opened up the mail on a Friday a while ago
and received a letter I think it was in September from HHA Secretary
Sibelius and Attorney General Holder. The letter expressed concern
about observed trends that might indicate, might indicate that
electronic health records are being used to perpetrate fraud. The
trends mentioned in the letter were particularly related to the coding
in it of evaluation and management services and indicated an intention
to have CMS recovery audit contractors, known as RACs, focus more
heavily on E and M billing and coding. Now the theory that electronic
health record templates or clinical note documentation inherently lead
to up coding is far from proven. In fact there is some evidence to the
contrary. In a December of 2012 article in the New England Journal of
Medicine the point was made that trends in higher E and M codes in
emergency rooms were actually linked to shifts in patient demographics
and a changing care delivery environment. Templates do serve as helpful
prompts and guides to remind health care providers to document
information that may not previously been written down or dictated into a
note. One of the goals of increasing the use of the EHRs was to
increase the accuracy of documentation. The use of a template to
encourage this increased accuracy does not deserve to automatically be
flagged as fraud and trigger a RAC audit. While we agree that some EHR
features have the potential for misuse, academic health centers have and
will continue to foster a culture of compliance and impose consequences
whenever necessary. Over the past several years our member institutions
have worked diligently to develop robust compliance and auditing
functions in order to prevent and if necessary respond to instances of
fraud, waste, and abuse. Indeed, a survey that we did of our members a
number of years ago demonstrated in place the comprehensive and costly
nature of these efforts. Chief compliance officers from our member
institutions participate in AAHC forum on regulation where they have
worked for some time to share best practices. In the past few years the
group has expressed concern about the availability of clear and useful
guidance on the coding and evaluation in management services. And in
AAHCs response to the September letter from HHS and DOJ we continued to
again express these concerns. AAHC believes the crux of the problem lies
in a system attempting to adjust to the future while still being rooted
in the past. Current billing and coding regulations reflect a practice
environment that is on its way to extinction. An environment in which
health care providers do their charts by hand, we can all think about
Marcus Welby, and keep paper records while serving a younger patient
population with fewer co-morbidities. For example current documentation
and payment guidelines for E and M services require inclusion of certain
data points, for example social history, past medical history, family
history in the note itself to justify a higher coding level. However
electronic health records are structured to allow for the storage of
these data points without including them in the note itself. Omitting
one or more of these data points from the note could lead to a
significant financial penalty, even though the information was
appropriately obtained by the provider. We strongly believe that
billing and coding regulations need to be updated to reflect the
changing demographics of the patient population and the rapidly evolving
practice environment of the future. A future where multiple providers
are collaborating with one another on a patient's care and increasing
amounts of data on the patient are digital. EHRs are designed to
enhance care coordination and communication by allowing multiple
providers to document the care of patient in a single note. This type
of collaborative documentation can reduce duplication, decrease
unnecessary errors, and streamline the process of caring for ailing
patients and supporting their caregivers. The result not only increases
efficiency but also improves the quality of care being provided.
Unfortunately in professional fee billing a single note is required for
each billing provider. And those single notes must include the same
items collected and already stored by other providers. I believe that
this example highlights the disparity between the regulations and the
way care actually needs to be delivered. AAHC and its forum on
regulation appreciate your willingness to explore and revise existing
policies to better reflect the use of electronic health records. We
would be most pleased to work with CMS and ONC to improve the available
guidance and increase clarity for our members and the health care
delivery system as a whole. Again, I thank you for the opportunity to
speak today and look forward to working with you on this important issue
in the future. applause