There are a number of codes available in the Current Procedural Terminology and the level of reimbursement is linked to the type of visit and the level of service provided. In general, consultations, new patients, and more complicated visits are associated with a higher level of reimbursement than routine established patient visits. The level of service is attached to a specific CPT code that is in turn matched to a fee. The level of service chosen is justified, however, by what is documented in the history and physical examination and by the associated complexity of medical decision making.

Medicare and Medicaid are payers (insurers) like anybody else, only they are run by the government with Medicare covering the elderly and Medicaid covering the indigent. Because Medicare is run by the federal government, they also take the lead in defining standards, and in fact have been the market's leading force in going electronic with 837s /835s and EFT payments.


Money Talks

The reason this electronic coding is so important comes down to money. The income of physicians is largely impacted by the fees attached to the CPT codes, and the rules surrounding how to determine which code to use for a specific encounter are complex.

Private committee surveys continue to show that physicians who code their own cases electronically have seen an increase of at least 30 percent in reimbursements, according to Blair C. Filler, MD, and a member of the AAOS Coding, Coverage and Reimbursement Committee.

"The number one way doctors get paid is they decide what type of visit it was and rank it on a scale of one to five with five being the highest and the number one source for payment to physicians overall," says Michael Stearns, president of e-MDs, which implements electronic health records. "The EHRs are a help in that because it helps doctors figure out what code to use and what goes into the claim. If they saw a patient and spend 45 minutes with them, they send a code attached to a certain fee that they expect to be paid."

If a physician was to enter a code for something not performed or supported properly by documentation, it could result in a rejected claim and may also lead to sanctions and financial penalties. Or, if they miscoded something by mistake, the same could happen.

Fearing the worst, often health care professionals enter codes that are lower than what would be appropriate for a specific visit, resulting in less reimbursement than they really deserve.

Over the past decade, EHRs have been responsible for eliminating such fears, as many systems are designed to improve coding accuracy and documentation through an automatic calculation of the level of service.

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