There are many interesting unintended consequences of electronic medical records (EMRs). I was reminded of this by a recent blog I wrote about what interns really do when they are on call. According to a study from a VA hospital using trained time-motion observers, interns spend 40% of their time on a computer and only 12% of their time taking care of patients. This meshes well with other reports noting that doctors are staring at screens instead of talking to patients.

Here’s the problem. The system actually rewards extensive documentation, which may result in less patient contact. The saying “If you didn’t document it, you didn’t do it” has morphed into “Document it, and you can use a higher billing code.”

Here are some billing codes for hospital visits:

99221 Initial Hospital Care, Physician spends 30 minutes at the bedside

99222 Initial Hospital Care, Physician spends 50 minutes at the bedside

99223 Initial Hospital Care, Physician spends 70 minutes at the bedside

Sources tell me that they know of physicians who never bill for less than 99223 or 70 minutes for a history and physical (H&P) examination. In order to do this the doctor must document such things as having reviewed at least 10 different systems (eg, respiratory, GI, musculoskeletal etc.). This is easy to document without having actually done it. The EMR may have popup windows with lists of systems and symptoms that can be checked off as reviewed.

This problem is more prevalent among the so-called “cognitive” specialties like internal medicine and primary care because for procedure-based specialties like surgery, the H&P is usually “bundled” (included) as part of the fee for the surgery.

Now that it is so easy to write a very detailed H&P, it must be tempting to bill every encounter at the maximum level. However, this may come back to bite those who try it. Medicare has been known to audit hospital charts and office records. They have profiles of what the distribution of the various levels of care should be.

Also, there are only so many hours in a day. Let’s say you are working a 12-hour shift and bill for eight 75 minute H&Ps and ten 25 minute subsequent visits. That’s 600 + 250 = 850 minutes or over 14 hours. If you are audited, you will have some explaining to do.

You may think that I am exaggerating but I am not the only one to raise this issue.

A recent long-read from the Center for Public Integrity confirms my thoughts. Here’s a quote from that piece, “And Medicare regulators worry that the coding levels may be accelerating in part because of increased use of electronic health records, which make it easy to create detailed patient files with just a few mouse clicks.

The article points out that billing for higher codes has risen over the last several years and it’s costing the taxpayers over $6 billion. It warns that Medicare audits might be forthcoming, but some feel that audits might cost more to perform than the revenue they generate.

We will see.

Skeptical Scalpel is a recently retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last two years, he has been blogging at and tweeting as @SkepticScalpel. His blog has had more than 340,000 page views, and he has over 4,200 followers on Twitter.