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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1995 and 1998 Chart Documentation Systems

The 1998 proposed HCFA documentation guidelines appear to provide better agreement with current family physician billing patterns than the 1995 guidelines. The levels of history achieved were very similar between the 1995 and 1998 guidelines. Higher levels of examination were much more difficult to achieve with the 1998 guidelines because of changes in the counting of examination items.

The determination of medical decision making changed in the 1998 guidelines to encompass just 3 types (low complexity, moderate complexity, and high complexity). In addition, the highest level achieved for any of the 3 components of medical decision making was enough to define the level, while 2 of 3 levels of the components were required with the 1995 guidelines to achieve a level of medical decision making. These changes made it easier to reach higher levels of medical decision making using the 1998 guidelines. The shift upward in levels of medical decision making using the 1998 guidelines was offset by the downward shift in the levels of examination.

Conclusions

Using the 1995 and 1998 guidelines, documentation supported the level of code selected in the majority of cases. When auditors disagreed with the code selected by the medical care provider, the documentation supported selection of a higher code than originally billed 4 times as often as it supported a lower code.

National coding systems used to determine levels of physician service should produce substantial interobserver agreement among reviewers and practicing physicians. If this system is used to determine physician fraud and assess penalties, consistency is tantamount. The 1995 and 1998 documentation guidelines fail to produce adequate concurrence among chart auditors for family practice patient office visits.

Acknowledgments

We would like to acknowledge those individuals who significantly assisted with the performance and publication of our study: Shirley Cresswell, Debbie Sanders, Darlene McComb, Sue Dalek, Larry Lalonde, Jan Goldberger, Jacqueline Schultz, Lynn Goldberger, Cyndi Coates, Robert Vitu, Sharon Sawyers, Peter Vasilenko, James Lafleur, John Clements, Kathi Kumar, Sue Davis, Jorge Plasencia, Michael Butman, Mitch Freeman, and John Cavendish.