Journal Logo



Feds Crack Down on Upcoding

Sorelle, Ruth MPH

doi: 10.1097/01.EEM.0000516448.14746.22
    upcoding, reimbursement
    upcoding, reimbursement:
    upcoding, reimbursement

    By the time the late President Lyndon B. Johnson signed the law establishing Medicare and Medicaid in 1965, the health care community was already figuring out how to maximize its returns from these new programs designed to insure the elderly, poor, and disabled. Those proceeds, however, have been generated over the years in ways that violated Medicare rules, resulting in billions of dollars in overpayments that had to be repaid with interest. More recently, the use of electronic medical records has enhanced facilities' ability to maximize those returns.

    As the totals invested in taking care of the nation's most vulnerable grew, so did the government's efforts to identify fraud and to cut costs. Notable among the cases identified were:

    • Columbia Hospital Corporation, founded in Texas by Rick Scott, who later became Florida's governor, bought HCA Healthcare, and the conglomerate admitted filing false claims to Medicare and other federal health programs. The company paid $1.7 billion in criminal fines, civil damages, and penalties in settlements with the U.S. Department of Justice in 2000 and 2002. Among the charges were that the hospital companies, alone and merged, billed Medicare and Medicaid for unnecessary tests or tests not ordered by a physician, attached false diagnosis codes to patient records to increase reimbursement, claimed marketing and advertising costs as community education, and billed for home health care visits for patients who were not qualified to receive them. (
    • MD2U, a Kentucky regional home health care provider, agreed to pay damages of $21.5 million last July to the federal government. The Department of Justice alleged that nurse practitioners were required to document that patients were home-limited or home-bound and could not make outpatient visits, even though some worked outside the home or went to school. The NPs were required to perform medically unnecessary visits and billed them at the highest level of the evaluation and management code required (so-called upcoding). The company's electronic medical record systems allowed the nurse practitioners to electronically cut and paste medical notes from prior visits, creating the impression that they were doing more work at each visit than they were. (
    • A whistleblower suit brought against Prime Healthcare Services, Inc., and its hospitals accused it of admitting patients with Medicare or private insurance from the ED and “upcoding by falsifying information concerning the complications and comorbidities associated with patients' diagnoses.” The Department of Justice intervened in the suit a year ago. (
    • A $60 million payment plus interest by the nationwide hospital staffing provider TeamHealth Holding settled allegations that its hospitalist group practice, IPC Healthcare, engaged in upcoding by billing Medicare, Medicaid, the Defense Health Agency, and the Federal Employee Health Benefits Program for more expensive services than were provided. ( The result of a whistleblower suit, the filing alleges that IPC, an acquisition of TeamHealth, encouraged its hospitalists to upcode services.

    Drift in Billing

    The emphasis on looking for upcoding as part of Medicare and Medicaid fraud efforts preceded the use of electronic medical records when the Centers for Medicare and Medicaid Services set up guides in 1992 for coding evaluation and management services, the cognitive services that are difficult to rate, even by the physicians who provide them. Jim Strafford, a consultant with 30 years' experience in documentation and coding, particularly in the emergency department, said he has seen a constant drift in billing levels in EDs, outpatient clinics, and hospitals. “Obviously, that means the government and insurance companies are going to pay more money. That is going to catch their attention.”

    The Center for Public Integrity analyzed Medicare payments in the nation's emergency departments in 2009 and found that billings increased by 64 percent between 2001 and 2008, adding more than $1 billion to the cost of the Medicare program. During that time, use of the two most expensive codes for evaluation and management went from 25 percent to 45 percent of all claims. (

    Mr. Strafford said he has puzzled over the trend and come up with some hypotheses about the increase. “Obviously, number one, the documentation has improved because of many things, one of which is EMRs. The government has incentivized the industry to put these in,” he said. But as with many government plans to reduce costs, this has been costly. One issue that arises, he said, is the amount of clicking required with EMRs. Physicians' notes are sometimes cloned from one day to the next. “Everything looks the same,” he said. It should be an easy hit for government auditors to “find out who is doing what,” he said. Is it a resident, a physician assistant, or a physician creating the medical document?

    Scribes — or “human Dictaphones,” as Mr. Strafford called them — add another layer of complexity to charting. EMRs created the field of scribes, he said. “Physicians hated the EMRs, the older ones especially,” he said. EMRs have changed documentation, he said; emergency physicians can no longer just “scribble in a chart.”

    Coding has become a numbers game, and to qualify for CPT 99285, the highest in the emergency department, the physician has to comply with many requirements, most of them driven by CMS. “It's a numbers game,” he said. The scribe plays a role by prompting the physician with, “Doc, you forgot to write down how severe the patient was.”

    Emergency physicians are also better educated about coding, Mr. Strafford said. “A better class of ER physicians and financial incentives are why coding has [become more expensive],” he said. “Watch out calling it upcoding. You can only call it that if it has been audited, and the audit calls it upcoded.”

    The ED as Hospital

    “There is no doubt that coding has changed,” said Stephen Pitts, MD, MPH, an associate professor of emergency medicine at the Emory University of School of Medicine in Atlanta. His study of emergency department discharges recorded in the National Hospital Ambulatory Medical Care Survey disproved the notion that patients are sicker. (N Engl J Med 2012;367[26]:2465.)

    “If there's been a change, it's in the other direction,” he said. “Nurse assessment at the front door has not changed.” He could not document more admissions either, which he said would occur if patients were sicker.

    He said many factors come into play, including that more patients are being seen, many of whom need diagnostic and treatment procedures. Dr. Pitts said the hospital expects the ED to make a diagnosis because they don't want to put a patient in a bed without knowing what the problem is. “The ER has become the hospital,” he said.

    Michael Granovsky, MD, the chair of the American College of Emergency Physicians reimbursement committee, said coding had also changed because the standard of care for evaluating a patient in the emergency department had gone up. “Previously, a patient came in with a hip fracture, you looked at him, decided the hip was broken, and sent [him] upstairs,” he said. “Now you do all the testing in the emergency department where previously it would have been done in the physician's office or upstairs in the hospital.”

    The Role of EMRs

    EMRs can also be pinpointed as a cause, reducing the number of patients seen in a shift, Dr. Pitt said, noting that “clicking on thousands” of check boxes slows you down. EMRs are meant to reduce errors, but have introduced their own problems, he said. “You can do an entire H&P, order chest x-rays, lipase, and other things. You hit enter, and realize it was the wrong patient. That is a serious medical error. You have to jump right on it.”

    Dr. Granovsky said the electronic medical record, meant to simplify charting, actually complicated the process. A certified electronic database can ultimately help by extracting meaningful data that help control cost, he said, but the one-size-fits-all of most hospital EMRs does not work for emergency physicians. “Documentation time has increased 200 percent,” Dr. Granovsky said. “One report found that it took more than 200 clicks to document upper right quadrant pain.” The variation of patients seen in the emergency department — sprained ankles, urinary tract infections, gunshot wounds, and chest pain — makes the typical EMR less than user-friendly.

    Increasing costs are the higher deductibles and copays faced by patients, which may make them choose an urgent care clinic over an emergency department. With lower acuity patients going elsewhere, emergency departments have a tough time being cost-effective. “Emergency physicians, working in an electronic medical record they didn't choose, are seeing acute, unscheduled patients who have any of the possible 50 to 100 diagnoses that comprise the top 90 percent,” Dr. Granovsky said.

    More than 1,500 ICD codes capture presentations to the ED, and EPs must then choose from about 69,000 diagnosis codes. Most emergency physicians labor through that EMR, work with a scribe, and deliver good patient care as part of the safety net, he said. Simplifying that situation and reducing costs, however, may be more than 200 clicks away.

    Wolters Kluwer Health, Inc. All rights reserved.