Medical decision making: guide to improved CPT coding.

Area of Science:

• Medical Coding
• Family Medicine
• Healthcare Administration

Background:

• The Current Procedural Terminology (CPT) coding system for office visits has been in use since 1995.
• Existing literature indicates significant variability in CPT code assignment among physicians and professional coders.
• Current coding practices often rely heavily on the extent of written documentation.

Purpose of the Study:

• To evaluate two novel methods for assessing appropriate CPT code assignment in office visits.
• To determine if CPT codes accurately reflect the level of medical decision-making or the sum of patient-mentioned problems.
• To identify the extent of undercoding in family medicine residency programs.

Main Methods:

• A professional coder, faculty member, and resident reviewed 351 randomly selected visit notes.
• Assessment included levels of documentation, medical decision-making, and total problems addressed.
• Appropriate CPT codes were assigned based on these three evaluated levels.

Main Results:

• Significant undercoding was observed across all assessed levels.
• 33% of visits were undercoded based on documentation alone.
• 50% were undercoded based on medical decision-making, and 80% based on the total number of patient problems.
• Interrater agreement was fair, consistent with previous coding studies.

Conclusions:

• Undercoding is prevalent in family medicine residency programs, extending beyond simple documentation audits.
• Failure to explore and document all patient problems contributes to undercoding.
• Minor adjustments in office visit documentation practices may benefit family physicians.