From the Field: I LIKE “POP”

Rick Collins

CMS’s Patients Over Paperwork (POP) initiative signals welcome relief from decades of increasingly oppressive documentation requirements. While the proposed changes to evaluation and management services (E&M) coding levels have grabbed headlines due to concerns about possible reduced reimbursement, there is great value in allowing providers to focus more on patient care and less on documentation.

For years providers have complained about the hoops they must jump through to be properly reimbursed for their services. Providers spend an inordinate amount of time documenting their services to satisfy payer and government agency regulatory requirements. The steady increase in the amount of required documentation has come at the same time reimbursement for services has declined.

The creation of electronic health records (EHRs) allowed providers to capture, organize, and manipulate data in ways not possible before, but many providers still report it takes them longer to document a visit in an EHR than on paper. EHR companies provided documentation and coding tools to help providers shorten the amount of time spent on documentation, but the temptation to improperly use shortcuts, e.g., cutting and pasting, have resulted in multitudes of providers being denied reimbursement for services genuinely rendered.

Medicare contractors and EHR companies have created coding assist tools to help providers code properly. However, when using these tools it is surprisingly easy for a Level 4 visit to be coded as a Level 2 because the provider forgot to include a seemingly small item in their visit record. When two providers perform the same service and one is paid at a Level 4 and the other at a Level 2 simply because one did not think to check a single box out of many choices, something is wrong with the system. Simplifying E&M coding to two levels, one for the most basic services and one for everything else, makes a lot of sense to me. The documentation requirements for the higher of the two levels are dramatically reduced from what they are currently.

Reduced documentation requirements would benefit providers in several important ways. First, the excessive amount of time currently required to completely document each patient encounter would be greatly reduced. Second, much less coding and documentation training and retraining would be required. Third, fewer providers would face losing their reimbursement due to technicalities. Fourth, providers would spend less time and money on audits and appeals. In short, providers would spend less time on documentation and administration and more time focused on patient care.

Regarding the potential drop in reimbursement for some providers, the big question is whether lower costs associated with reduced documentation would offset a potential drop. In addition to looking at actual dollars saved, providers should consider how their individual time and quality of life would be affected. Also, if less time were spent on documentation, would there be time to see additional patients, thus generating additional reimbursement not possible under the current requirements?

In visiting with renal providers, a number have expressed great frustration with current coding and documentation requirements. Many face increasing pressure from payers who target nephrologists as coding too high compared with other providers, even other nephrologists. Payers may demand extensive supporting documentation for past visits. Depending on what payers find when they review the documentation, they may recoup money previously paid for all or part of the provider’s services.

The pressure applied by payers to bill with lower coding levels has frightened a number of nephrologists into coding at more “safe” levels, such as a Level 3, even though they believe their documentation supports a higher level. When nephrologists pursue this safe course, it lends credence to the payers notifying other nephrologists that their coding levels are higher than other nephrologists. Providers with higher coding levels draw the attention of payers and these providers, even if they are coding correctly, are required to spend a considerable amount of time and labor submitting documentation to support their coding. Reimbursement can be delayed or recouped and some providers determine it is not worth the fight so they begin coding at lower levels. The proposal to reduce the number of E&M levels to two would likely curtail or possibly eliminate this problem with payers.  That, in and of itself, would be worth a lot.

Rick Collins is the director of business development for Sceptre Management Solutions, LLC., a company specializing in billing for outpatient ESRD facilities, nephrology practices, and vascular access. Your questions are welcome and he can be reached at or 801.775.8010.