Appropriateness criteria and elective procedures--total joint arthroplasty.

adapted: some have become stu­ dents of the coding procedures, but many have outsourced billing to professional coders trained to search for keywords. Although many ED physicians don’t know exactly what is billed in their name, physicians commonly re­ ceive regular feedback on their average billing performance through automated reports. Early adoption of electronic records by the ED may in part explain the sharper billing in­ creases in emergency medicine than in other clinical specialties. The EHR facilitates billing by presenting clickable check­boxes that easily satisfy coding­com­ plexity criteria, and some EHRs even issue notifications when documentation needed for cer­ tain billing levels has not been achieved. These changes ensure that no billable action goes un­ noticed and have reduced under­ coding. In fact, EHR vendors tout this effect to justify the cost of their products. In other ways, however, the EHR has become a double­edged sword, potentially undermining its intended goal of reducing medical errors. Through­ put suffers when time that could be better spent with patients is wasted on elaborate documenta­ tion. The EHR may also facilitate improper behavior, such as click­ ing multiple items in the “review of systems” that patients were not directly asked about. Of even greater concern is the possibility of deliberate, systematic use of easily selected templates designed to ensure billing at the highest possible level, rather than pro­ moting validated clinical deci­ sion rules and protocols designed to improve efficiency and quality. Although ED physicians are in­ creasingly employed by hospitals, hospital chains, or contract groups with productivity­based compen­ sation,5 the OIG holds individual physicians accountable for billing done in their name, regardless of who directly manages the billing operations. What should be done about the trend in billing? A first step is to do what the OIG report pro­ poses: educate physicians about the importance of proper billing, review billing records to ensure that results match performance, and scrutinize physicians who consistently bill at higher levels than their peers.1 From a broader perspective, the science of ED operations should be advanced to facilitate timely care. These ad­ vances should include the devel­ opment of a more effective busi­ ness model for the digital era that allows ED practitioners to get away from the computer and back to the bedside of sick and injured patients. The EHR is one reason behind increased ED billing, and fraud may be facilitated by these new systems. However, this simple ex­ planation does not capture the broader story of what happened in U.S. EDs during the decade the OIG examined. While the ED has remained the social safety net, it has also gradually inherited roles previously handled by office­ based physicians. EDs have be­ come a central staging area for acutely ill patients, for the use of diagnostic technology, and for de­ cisions about hospital admission, all of which makes ED care in­ creasingly complex.