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    Accuracy of EM Coding by Coders and Doctors
    By Barbara Cobuzzi - Posted on 03 May 2010

    I have come across some very interesting articles and abstracts with the help of some of my colleagues (Leslie, Sheri, thank you) and I think that they should be shared. These articles are very interesting, especially if you get audited:

    http://www.aafp.org/fpm/2005/0600/p17.html
    http://www.jabfm.com/cgi/content/abstract/14/3/184
    http://archinte.ama-assn.org/cgi/content/abstract/162/3/316


    The last one is an abstract, so I pulled up the full article at
    http://archinte.ama-assn.org/cgi/content/full/162/3/316

    and I think you will find the last two paragraph which conclude the paper of great interest. I will paste them here:

    Although coding errors might conceivably relate to financial incentives or potential legal penalties, the format of the study was designed to test the coding specialists' accuracy in coding using hypothetical cases. This design removes any financial or legal incentives for incorrect coding. All coding specialists coded from the same typewritten progress notes, thus removing the discrepancies from attempting to interpret handwritten progress notes or apply the guidelines to different cases of the same coding level. Despite removing these potential sources of coding inaccuracy, the error rate was still high, with 44% of coding specialists agreeing with the consensus response on 3 or fewer cases, and 8% agreeing with the consensus code on 1 or none of the cases. However, only 3% of established patient codes and 8% of new patient codes were more than 1 coding level different from the consensus code. Thus, although there seems to be a high background error rate for CPT coding among coding specialists, most errors are within 1 level of the correct code. This finding is consistent with findings from the physicians coding study by Kikano et al4 who found that physicians' codes differed from reviewers' codes by more than 1 level in fewer than 4% of cases. Unless this intrinsic coding error rate is accounted for, identification of fraudulent coding practices would be extremely difficult.

    From our results, it seems that the error rate with CPT coding is substantial for coding specialists as well as physicians. This would suggest that the guidelines themselves are overly complex and open to subjective interpretation which then creates a high inherent error rate. Having separate sets of guidelines for new and established patients may be a contributory factor. One possible solution to minimizing the error rate with CPT coding would be to standardize the coding criteria into 1 set of guidelines for all patients. In addition, decreasing the number of potential codes for each office visit as well as the number of steps required to arrive at a code would limit the potential for error and subjective interpretations. Another proposed solution6 involves using time and new vs established patient status as the deciding factors in arriving at the level of service provided. Finally, given the complexity of the current CPT guidelines, another potential solution is to accept an inherent error rate. Clearly, further study of the CPT coding guidelines is warranted.

     

    2010 CPT Code Changes

    Guidelines

    Evaluation & Management Services Guide (CMS-July 2009)
    1997 E/M Documentation Guidelines
    1995 E/M Documentation Guidelines
    E/M Pocket Guide (Trailblazer Health: 2008)

    History Documentation

    Documenting a History (Tulane University Medical Group)
    Highmark Medicare Services HPI Elements (Reviewed 05/13/08)

    FAQ

    Highmark Medicare Services FAQ (Reviewed 2/13/2008)
    Wisconsin Medical Society FAQ (2008)
    Medicare Physician Guide (CMS-July 2007)
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