Variability in Code Selection Using the 1995 and 1998 HCFA Documentation Guidelines for Office Services - Health Care Financing Administration

Journal of Family Practice, July, 2000 by Thomas J. Zuber, Christopher E. Rhody, Theresa A. Muday, Edward A. Jackson, Stuart J. Rupke, Leslie Francke, Walter T. Rathkamp

* BACKGROUND Documentation guidelines have been developed by the Health Care Financing Administration (HCFA) to promote consistent selection of physician evaluation and management (E & M) codes. Our goals were to determine whether medical providers and auditors agree in their assignment of office codes using 1995 and 1998 guidelines and to ascertain if the code levels assigned are affected by auditor experience and training.

* METHODS A total of 1069 established patient charts from private family physician offices were reviewed by a family practice faculty physician, a family practice resident physician, and a professional coder. The main outcome measures were the agreement between the auditors and the medical care provider on code selection and the degree to which documentation supported the code selected.

* RESULTS All auditors agreed with the medical provider code selection in only 15.2% (1995 guidelines) and 29.2% (1998 guidelines) of visits. Professional coders were more likely than faculty physicians or resident physicians to agree with the code assigned by the medical provider (51.7% vs 40.7% and 39.6%, P [is less than] .001). Documentation adequately supported the most common office code selection, 99213, in 92.7% (1995) and 91.0% (1998) of the charts reviewed. Concurrence among all auditors was only 31.0% (1995) and 44.3% (1998).

* CONCLUSIONS Interobserver differences exist in the assignment of E & M codes by auditors using both 1995 and 1998 HCFA guidelines. The 1998 documentation guidelines produce greater agreement among auditors. The documentation supported the level of code billed in the majority of established patient office visits.

* KEY WORDS Guidelines; fraud; United States Health Care Financing Administration. (J Fam Pract 2000; 49: 642-645

In 1992, the American Medical Association (AMA) adopted modifications to the Current Procedural Terminology (CPT) codes used for reporting physician evaluation and management (E & M) services.[1-5] Code levels were determined in the majority of visits by the degree of history taking, the physical examination performed, and the complexity of the medical decision making required to provide patient care.[4,6-8] These 3 contributory factors in code determination became known as the key components. The Health Care Financing Administration (HCFA) provided guidelines for the required documentation to support the level of visit coded, and modified the guidelines further in 1995 and 1997.[9] The 1997 guidelines were not well received by many medical groups,[3,9-12] and the adoption of those guidelines was postponed.[9] The HCFA released a new proposed set of documentation guidelines in late 1998,[12,13] but at the time of this study those guidelines had not been field tested.

Increasing concern about inaccurate coding and fraudulent billing has led to audits of physician billing practices.[14,15] The Office of the Inspector General of the Department of Health and Human Resources has stated that approximately 40% of physician payments questioned at audit involved insufficient chart documentation.[15] Huge dollar losses to the Medicare program have been extrapolated from small federally sponsored audits.[15]

Studies of billing and coding practices have demonstrated poor agreement between the code level and medical record documentation.[1,16,17] A recent study by Chao and colleagues[1] demonstrated only a 55% concordance rate between the billing codes assigned in the office and those assigned by direct observation.

Our study was undertaken to evaluate the level of agreement among physician and nonphysician auditors with office code selections by practicing family physicians. Chart evaluations were performed by physician reviewers with extensive practice experience (faculty), younger and less-experienced physicians (residents), and trained chart auditors (professional coders). We performed direct comparison of the 1995 and 1998 documentation guidelines.

METHODS

Source of Data

Five private family physician offices, including 10 medical providers (9 physicians, 1 family nurse practitioner) volunteered to participate. No documentation training was given to the medical providers before initiating the study.

Consecutive billing sheets or computer sheets describing the level of established patient evaluation and management service billed between July 1998 and January 1999 were selected and placed on top of the corresponding chart. The medical providers were blinded to which charts would be audited.

Supporting documentation for this audit was limited to information recorded in the progress note on the date of service, unless the note directed the reviewer to another section of the chart. For example, medications recorded on a separate page were not included as documentation unless a specific reference was made to that page.

Documentation

The 1995 documentation guidelines were selected because of the poor physician acceptance of the 1997 guidelines. The checklist for the 1995 guidelines was created using a modification of the worksheet of the E/M Documentation Auditors' Instructions.[18] The checklist for the proposed 1998 guidelines was created from a document released by the AMA in November 1998.[19]