To the Editor Changes in medicine do not occur in a vacuum. In a research letter published in a recent issue of JAMA Internal Medicine, Nie et al suggest evidence of upcoding by anesthesiologists but ignore several explanations.1
First, expanding use of electronic medical records (EMRs) occurred from 2005 to 2013. More complete preoperative assessments are facilitated by such access.2,3 Second, EMRs can produce unintended errors that affect coding, including the source of the American Society of Anesthesiologists (ASA) classification.4 Nonanesthesiologists have been shown to markedly underestimate ASA physical status5 out of ignorance, to avoid anesthesia consultation for sedation services, or to allow the use of the Sedasys system (patients with ASA physical status rating 1-2 only). Third, patients are older, sicker, and heavier: sleep apnea—or at least our recognition of it and its risks—is more prevalent, for example.1 These data show changes in coding practices but are not evidence of upcoding, deliberate or otherwise.