Original Article

Medical Decision Making: Guide to Improved CPT Coding

Authors: Jim Holt, MD, Ambreen Warsy, MD, Paula Wright, CPC-E/M, CPMA

Abstract

Background: The Current Procedural Terminology (CPT) coding system for office visits, which has been in use since 1995, has not been well studied, but it is generally agreed that the system contains much room for error. In fact, the available literature suggests that only slightly more than half of physicians will agree on the same CPT code for a given visit, and only 60% of professional coders will agree on the same code for a particular visit. In addition, the criteria used to assign a code are often related to the amount of written documentation. The goal of this study was to evaluate two novel methods to assess if the most appropriate CPT code is used: the level of medical decision making, or the sum of all problems mentioned by the patient during the visit.


Methods: The authors–a professional coder, a residency faculty member, and a PGY-3 family medicine resident–reviewed 351 randomly selected visit notes from two residency programs in the Northeast Tennessee region for the level of documentation, the level of medical decision making, and the total number of problems addressed. The authors assigned appropriate CPT codes at each of those three levels.


Results: Substantial undercoding occurred at each of the three levels. Approximately 33% of visits were undercoded based on the written documentation. Approximately 50% of the visits were undercoded based on the level of documented medical decision making. Approximately 80% of the visits were undercoded based on the total number of problems which the patient presented during the visit. Interrater agreement was fair, and similar to that noted in other coding studies.


Conclusions: Undercoding is not only common in a family medicine residency program but it also occurs at levels that would not be evident from a simple audit of the documentation on the visit note. Undercoding also occurs from not exploring problems mentioned by the patient and not documenting additional work that was performed. Family physicians may benefit from minor alterations in their documentation of office visit notes.


Key Points


* All previous studies of CPT coding have audited the written encounter note.


* Medical decision making (MDM) is the most appropriate basis for selecting the CPT code for an office visit, as long as the history or the physical exam documentation also support that level.


* Using MDM to retrospectively audit office visit notes showed that 50% of visits were undercoded. A small amount of additional documentation would allow the higher code.


* Addressing all patient-mentioned problems during the visit, although clearly more time-consuming, would allow a higher CPT code to be used for 80% of the audited visits.

This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($25)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. King MS, Sharp L, Lipsky MS. Accuracy of CPT evaluation and management coding by family physicians. J Am Board Fam Pract 2001;14:184–192.
 
2. Kikano GE, Goodwin MA, Stange KC. Evaluation and management services. A comparison of medical record documentation with actual billing in community family practice. Arch Fam Med 2000;9:68–71.
 
3. Chao J, Gillanders WG, Flocke SA, et al. Billing for physician services: a comparison of actual billing with CPT codes assigned by direct observation. J Fam Pract 1998;47:28–32.
 
4. King MS, Lipsky MS, Sharp L. Expert agreement in current procedural terminology evaluation and management coding. Arch Intern Med 2002;162:316–320.
 
5. Fillit H, Geldmacher DS, Welter RT, et al. Optimizing coding and reimbursement to improve management of Alzheimer's disease and related dementias. J Am Geriatr Soc 2002;50:1871–1878.
 
6. Beasley JW, Hankey TH, Erickson R, et al. How many problems do family physicians manage at each encounter? A WReN study. Ann Fam Med 2004;2:405–410.
 
7. Duszak R, Blackham WC, Kusiak GM, et al. CPT coding by interventional radiologists: a multi-institutional evaluation of accuracy and its economic implications. J Am Coll Radiol 2004;1:734–740.
 
8. Dustman R. Report Indicates Most Over-Utilized Codes. Salt Lake City, UT, AAPC Coding Edge, February, 2008.
 
9. List of Over-Utilized Codes, FY 2007, Comprehensive Error-Rate Testing Program. CMS. Available at: www.cms.hhs.gov. Accessed November 15, 2007.
 
10. Cigna Government Services. Progressive corrective action on established office visit, CPT code 99215. Available at: http://www.cignagovernmentservices.com/partb/pubs/news/2005/0705/Cope2715.html. Accessed May 21, 2008.
 
11. The False Claims Act (31 U.S.C. § 3729).