Accuracy of CPT Evaluation and Management Coding by Family Physicians
Accuracy of CPT Evaluation and Management Coding by Family Physicians
Background: Limited data are available on physicians' accuracy in coding for their services. The purpose of this study was to determine the current procedural terminology (CPT) evaluation and management coding accuracy of family physicians and define demographic variables associated with coding accuracy.
Methods: Six hundred randomly selected active members of the Illinois Academy of Family Physicians were sent six hypothetical progress notes of office visits along with a demographic survey. The study group assigned CPT evaluation and management codes to each of the progress notes and completed the demographic survey. Five expert coders also assigned codes to each of the cases. The accuracy of family physicians in determining CPT E/M codes was determined relative to that of expert coders.
Results: Family physicians agreed with the experts' CPT evaluation and management codes for 52% of established patient progress notes, the most common error being undercoding. In contrast, for new patient progress notes, family physicians agreed with the experts only 17% of the time, the predominant error being overcoding. No surveyed demographic variable was associated with coding accuracy.
Conclusions: The error rate for physician CPT coding is substantial and occurs more commonly with new patients. The complexity of the CPT coding guidelines, along with limited physician training in CPT coding, likely account for these results.
Currently there is a great deal of interest by the government and in the lay press on current procedural terminology (CPT) coding. CPT guidelines mirror the change from a charge-based system to a fee schedule that reflects the resources used in providing care. Clinicians use CPT codes to bill Medicare and other payors for their services. Despite the importance of the CPT codes, however, there is limited research regarding physician coding. For example, only three studies evaluated coding using current CPT evaluation and management guidelines, and only one study included new patient visits. As a result, there is little information regarding physician coding accuracy, physician training in CPT coding, or characteristics associated with accurate or inaccurate coding.
There are several reasons why coding is an important topic for physicians. The most obvious is financial, because coding determines reimbursement for physician services. Available data suggest that physicians code improperly, with conflicting data on the net economic impact of this inaccuracy. Information from Health Care Finance Administration (HCFA) and the American Academy of Family Physicians (AAFP) indicate that family physicians often undercode for their services, resulting in a loss of potential revenues. Conversely, the Office of the Inspector General recently issued a release citing $20 billion of Medicare overpayments with 29% due to improper coding for physician's services. A recent study using trained observers and current CPT guidelines found that physicians' CPT codes for established patients agreed with the observers' codes 55% of the time, with approximately an equal amount of undercoding and over-coding. A retrospective chart review by Zuber and associates had similar results. In the only study to include new patient visits, a retrospective chart review by Kikano et al, 46% of physician CPT evaluation and management codes agreed with the reviewers, but with a greater tendency to overcode new patients.
Despite revisions, many believe that the CPT evaluation and management coding guidelines are clinically irrelevant and overly complex. One explanation for inaccurate coding could be the complexity of the coding system and a poor understanding on the part of physicians regarding their use. Informal discussions with physicians suggest that inaccurate coding is more likely due to the difficulty of transferring coding guidelines into clinical practice rather than to fraudulent activity.
Coding properly has important legal as well as financial implications. For example, accurate evaluation and management coding can help protect physicians from the financial and legal ramifications of a Medicare audit. In training programs, the coding level documents a faculty member's involvement with a patient's care, touching on both legal and more complicated financial concerns. Against a background of several well-publicized audits of academic medical centers, these issues are critically important.
In this study we examined how accurately a sample of family physicians code outpatient visits. In addition, we sought to find out whether certain characteristics, such as practice setting, charges for different office visit levels, and training in CPT coding, are associated with coding accuracy. The results might help to target interventions to selected groups or settings where the coding guidelines might be applied less accurately. The data might also be helpful in determining a natural background error rate for coding. This natural error rate could help distinguish between fraudulent billing practices and the impossibility of applying a complex system with perfect accuracy.
Abstract and Introduction
Abstract
Background: Limited data are available on physicians' accuracy in coding for their services. The purpose of this study was to determine the current procedural terminology (CPT) evaluation and management coding accuracy of family physicians and define demographic variables associated with coding accuracy.
Methods: Six hundred randomly selected active members of the Illinois Academy of Family Physicians were sent six hypothetical progress notes of office visits along with a demographic survey. The study group assigned CPT evaluation and management codes to each of the progress notes and completed the demographic survey. Five expert coders also assigned codes to each of the cases. The accuracy of family physicians in determining CPT E/M codes was determined relative to that of expert coders.
Results: Family physicians agreed with the experts' CPT evaluation and management codes for 52% of established patient progress notes, the most common error being undercoding. In contrast, for new patient progress notes, family physicians agreed with the experts only 17% of the time, the predominant error being overcoding. No surveyed demographic variable was associated with coding accuracy.
Conclusions: The error rate for physician CPT coding is substantial and occurs more commonly with new patients. The complexity of the CPT coding guidelines, along with limited physician training in CPT coding, likely account for these results.
Introduction
Currently there is a great deal of interest by the government and in the lay press on current procedural terminology (CPT) coding. CPT guidelines mirror the change from a charge-based system to a fee schedule that reflects the resources used in providing care. Clinicians use CPT codes to bill Medicare and other payors for their services. Despite the importance of the CPT codes, however, there is limited research regarding physician coding. For example, only three studies evaluated coding using current CPT evaluation and management guidelines, and only one study included new patient visits. As a result, there is little information regarding physician coding accuracy, physician training in CPT coding, or characteristics associated with accurate or inaccurate coding.
There are several reasons why coding is an important topic for physicians. The most obvious is financial, because coding determines reimbursement for physician services. Available data suggest that physicians code improperly, with conflicting data on the net economic impact of this inaccuracy. Information from Health Care Finance Administration (HCFA) and the American Academy of Family Physicians (AAFP) indicate that family physicians often undercode for their services, resulting in a loss of potential revenues. Conversely, the Office of the Inspector General recently issued a release citing $20 billion of Medicare overpayments with 29% due to improper coding for physician's services. A recent study using trained observers and current CPT guidelines found that physicians' CPT codes for established patients agreed with the observers' codes 55% of the time, with approximately an equal amount of undercoding and over-coding. A retrospective chart review by Zuber and associates had similar results. In the only study to include new patient visits, a retrospective chart review by Kikano et al, 46% of physician CPT evaluation and management codes agreed with the reviewers, but with a greater tendency to overcode new patients.
Despite revisions, many believe that the CPT evaluation and management coding guidelines are clinically irrelevant and overly complex. One explanation for inaccurate coding could be the complexity of the coding system and a poor understanding on the part of physicians regarding their use. Informal discussions with physicians suggest that inaccurate coding is more likely due to the difficulty of transferring coding guidelines into clinical practice rather than to fraudulent activity.
Coding properly has important legal as well as financial implications. For example, accurate evaluation and management coding can help protect physicians from the financial and legal ramifications of a Medicare audit. In training programs, the coding level documents a faculty member's involvement with a patient's care, touching on both legal and more complicated financial concerns. Against a background of several well-publicized audits of academic medical centers, these issues are critically important.
In this study we examined how accurately a sample of family physicians code outpatient visits. In addition, we sought to find out whether certain characteristics, such as practice setting, charges for different office visit levels, and training in CPT coding, are associated with coding accuracy. The results might help to target interventions to selected groups or settings where the coding guidelines might be applied less accurately. The data might also be helpful in determining a natural background error rate for coding. This natural error rate could help distinguish between fraudulent billing practices and the impossibility of applying a complex system with perfect accuracy.
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