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Variability in code selection using the 1995 and 1998 HCFA documentation guidelines for office services. Health Care

T J Zuber1, C E Rhody, T A Muday

  • 1Department of Family Medicine, Saginaw Cooperative Hospitals and Michigan State University, 48602, USA. zuber@pilot.msu.edu

The Journal of Family Practice
|August 3, 2000
PubMed
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Physician code assignment shows low agreement between providers and auditors, though newer guidelines improve consistency. Documentation generally supports billed evaluation and management (E & M) codes.

Area of Science:

  • Medical Coding and Billing
  • Healthcare Administration
  • Health Services Research

Background:

  • The Health Care Financing Administration (HCFA) developed documentation guidelines to standardize physician evaluation and management (E & M) code selection.
  • Variability in E & M code assignment can impact healthcare reimbursement and practice efficiency.

Purpose of the Study:

  • To assess agreement in office E & M code assignment between medical providers and auditors using 1995 and 1998 HCFA guidelines.
  • To determine if auditor experience and training influence the assigned E & M code levels.

Main Methods:

  • Review of 1,069 established patient charts from family physician offices.
  • Independent chart review by a faculty physician, a resident physician, and a professional coder.

Related Experiment Videos

  • Comparison of auditor code selections with the medical provider's assigned code and assessment of documentation support.

    • Main Results:

    • Auditor agreement with the medical provider's code selection was low: 15.2% (1995) and 29.2% (1998).
    • Professional coders showed higher agreement (51.7%) with provider codes compared to faculty (40.7%) and resident physicians (39.6%).
    • Inter-auditor agreement was 31.0% (1995) and 44.3% (1998); the 1998 guidelines improved this.

    Conclusions:

    • Significant interobserver variability exists in E & M code assignment under both 1995 and 1998 HCFA guidelines.
    • The 1998 documentation guidelines demonstrated improved agreement among auditors.
    • Documentation adequately supported the billed E & M code levels in most reviewed cases.