Variability in Code Selection Using the 1995 and 1998 HCFA Documentation Guidelines for Office Services

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Original Research

Variability in Code Selection Using the 1995 and 1998 HCFA Documentation Guidelines for Office Services

J Fam Pract. 2000 July;49(7):642-645

References

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Chart Evaluators

Four faculty physicians, 6 resident physicians, and 6 professional coders volunteered to participate as chart auditors in our study. Auditors attended 2 training sessions on the application of the HCFA chart documentation guidelines conducted by T.Z. An additional pilot audit was performed by the reviewers at one site to gain experience with the work sheet. Auditors were permitted to use copies of the 1995 auditor’s instructions and the AMA summary of the 1998 guidelines to assist them during the audits. Once the work sheets were completed, they were not seen by the other auditors.

Results

Evaluation of the Medical Provider Code Selection

Audits were performed on 1069 charts. Agreement with the medical provider code selection was better for all 3 auditors (faculty, residents, and coders) with the 1998 guidelines. The coders differed significantly (P <.001) from the faculty and resident physician auditors in their greater agreement with the code selected by the medical provider. There was no statistical difference between the faculty and resident physician auditors (P=.604 for 1995; P=.799 for 1998) in their level of agreement with the medical provider’s code selection.

The [Figure] shows the numbers and percentage of each established patient code selection found by the auditors to have sufficient documentation to meet or exceed that level. In 69.5% of established patient visits reviewed, the code 99213 was billed. For this code, faculty noted that the documentation was sufficient for 92.7% (1995) and 91.0% (1998) of the visits, resident physicians for 81.3% (1995) and 83.6% (1998), and professional coders for 82.9% (1995) and 95.6% (1998).

All auditors agreed with the medical provider code selection for only 15.2% (1995) and 29.2% (1998) of the charts reviewed. Concordance among auditors for code determination was 30.4% (1995) and 42.5% (1998). When auditors disagreed with the code selected by the medical provider, the documentation supported a code higher than the one billed 4 times as often as insufficient documentation.

Evaluation of the 1995 and 1998 Documentation Guidelines

The visits billed as 99213 by the medical provider yielded the largest amount of data in comparing the documentation systems. Few differences were noted between the 1995 and 1998 documentation systems for the levels of history. The change in the counting of examination items in the 1998 guidelines produced lower levels of examinations. For all auditors, there was a 34-fold drop (68.6% vs 2%) in detailed examinations from the 1995 guidelines to the 1998 guidelines. Higher levels of medical decision making were achieved using the 1998 guidelines. Moderate complexity medical decision making was noted 6 times more often using the 1998 guidelines.

Discussion

Code Selection

The selection of office evaluation and management codes appears to be subjective, with significant degrees of difference noted between physicians and professional coders using the same guidelines. There was no statistical difference in code selection between resident physicians (with only 2.3 years of coding experience) and attending physicians (with 23.3 years of coding experience). The variance we noted between physicians and professional coders is a significant issue in the specialty of family practice, where the majority of patient care involves the reporting of E & M codes. Future systems used to evaluate chart documentation must demonstrate greater interobserver agreement.

Inadequate Chart Documentation

Auditors often observed that documentation of work performed during the visit appeared in the chart outside the progress note (such as on medication lists or on vital signs sheets), but this information was not referenced according to the audit rules. Physicians might significantly improve documentation by routinely incorporating some reference in the progress note to alternate information in the chart. The future use of electronic medical records may eliminate this problem by allowing chart reviewers to access more of the work actually being performed by medical providers. Alternatively, the HCFA could modify its rules to include this information automatically.

Underreporting of Work Performed

We noted that the documentation often supported a higher code than was originally billed. This tendency toward undercoding may reflect physician fear of audits or regulatory agencies. Physicians also may be uncomfortable or lacking in knowledge of cumbersome coding rules and documentation guidelines, and guessing or routine code assignments may play a role in code selection. The high degree of underreporting in our study makes it unlikely that intentional efforts exist to bill for work not performed.

This is one of the largest physician-directed documentation audits undertaken. It is possible that physician auditors view documentation differently from nonphysician auditors. Our finding that the professional coders agreed with the medical provider’s code selection more often than the faculty or resident physicians for both the 1995 and 1998 documentation guidelines was unexpected. The assumption that the coders would assign lower code levels was not confirmed by our study.