Physician care evaluation and management documentation and coding: An exploratory study of policy inertia and technology adoption

Objective. This study of evaluation and management (E/M) documentation and coding methods explored (1) the policy implications of the continued use of the E/M coding system, (2) the level of E/M documentation and coding technology and possible relationships with practice characteristics, (3) the possible impact of organizational and environmental factors upon the level of E/M documentation and coding technology adoption.; Design. Two data sources were used: a web-based survey created via a combination of interviews, site visits and focus groups and the 2005 Area Resource File.; Results. Evaluation and Management code assignment essentially represents the ability of the practitioner to document according to payer guidelines, especially those promulgated by the Centers for Medicare and Medicaid Services (CMS). After fourteen years of use, no studies were found in which E/M code assignment was deemed to adequately represent the quality or type of care delivered. Further, E/M coding has a low reliability rate and new codes and reporting requirements are being implemented in order to meet the needs of quality and performance measurement.; Physician practices continue to use the traditional methods of documentation technology such as handwriting and dictation, even when also utilizing technology such as computerized templates or an electronic health record (EHR). Even lower levels of technology adoption were observed for coding technology with only approximately one-half of the practices using an EHR taking advantage of coding technology for E/M code assignment.; Organizational size, the number of physicians in the practice, was found to be highly predictive of whether or not documentation and coding technology were used. County or regional characteristics of the practice setting, environmental factors, were not found to be predictive of whether or not documentation and coding technology was utilized.; Conclusions. (1) The E/M coding system does not meet the needs of today's health care system and suffers from a low rate of reliability. (2) The low levels of E/M documentation and coding technology may be due to the legal and regulatory penalties associated with coding errors or inaccuracy. This research suggests that, even when there may be financial incentives in the form of increased reimbursement to adopt a technology, legal and regulatory barriers such as increased auditing and the fear of being accused of fraud can be difficult to surmount. (3) Policy makers should focus on financial incentives for small organizations in order to accelerate the adoption of HIT.