Evaluation and management services - A comparison of medical record documentation with actual billing in community family practice

Objective: To compare the concordance of family physicians' billing for eva luation and management services with medical record documentation. Design: Multimethod, cross-sectional observation study. Setting: Eighty-four family practices in northeast Ohio. Participants: Four thousand fifty-four outpatients visiting 138 family phys icians. Main Outcome Measure: The degree of concordance between evaluation and mana gement Current Procedural Terminology codes billed by physicians, with thos e codes assigned by trained research nurses using American Medical Associat ion criteria to code medical records for the same visits. Results: Discrepancies between the multifactorial nature of family practice outpatient visits and the Current Procedural Terminology coding criteria, which dictate overcoding for depth rather than breadth, made coding difficu lt (multiple-rater kappa. statistic between research nurses = 0.36).Among 4 137 outpatient visits with complete billing information, 57% of the Current Procedural Terminology codes generated by medical record review were conco rdant with the actual billing code assigned by physicians. Undercoding and overcoding occurred at a similar frequency (21% and 19%, respectively) and differed by more than 1 code in fewer than 4% of visits. Visits by new pati ents were more likely to be inaccurately coded than visits by established p atients. Conclusions: Record documentation by community family physicians largely re flects the level of services billed using evaluation and management codes. Undercoding is as common as overcoding. Efforts from regulatory agencies sh ould be redirected from penalizing physicians for overcoding to focusing on the development of coding criteria that reflect the multifactorial nature of outpatient primary care practice.