Variability in code selection using the 1995 and 1998 HCFA documentation guidelines for office services. Health Care Financing Administration

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 1,069 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 <.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.

Getting tough with home health accounts receivable

Home health organizations seeking to improve the performance of their accounts receivable should concentrate first on establishing practices that promote the greatest percentage of clean claims and reviewing payments received to be sure rates paid are optimal. They also may find it worthwhile to survey their business office operations for potential improvements to key areas.

Trends in outsourcing. Anatomy of a customer care solution

Greenwich Hospital, Greenwich, Conn.

PROBLEM

The hospital had a history of complex and confusing patient billing forms and in at least one instance the billing department was unreasonably unresponsive to a patient's needs.

SOLUTION

Officials in the hospital's patient and guest relations department began outsourcing services to address the billing needs of the hospital and the patients.

RESULTS

After the hospital overhauled its billing procedures, complaints dropped and bad debts came in far below budget.

KEYS TO SUCCESS

"The hard work includes establishing advisory boards and task forces to examine new ways to communicate better with patients."

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