| Medical decision making: guide to improved CPT coding. | |
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MedLine Citation:
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PMID: 20224505 Owner: NLM Status: MEDLINE |
Abstract/OtherAbstract:
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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. |
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Authors:
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Jim Holt; Ambreen Warsy; Paula Wright |
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Publication Detail:
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Type: Journal Article |
Journal Detail:
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Title: Southern medical journal Volume: 103 ISSN: 1541-8243 ISO Abbreviation: South. Med. J. Publication Date: 2010 Apr |
Date Detail:
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Created Date: 2010-06-07 Completed Date: 2010-07-13 Revised Date: - |
Medline Journal Info:
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Nlm Unique ID: 0404522 Medline TA: South Med J Country: United States |
Other Details:
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Languages: eng Pagination: 316-22 Citation Subset: AIM; IM |
Affiliation:
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Department of Family Medicine, Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA. holtj@etsu.edu |
Export Citation:
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| MeSH Terms | |
Descriptor/Qualifier:
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Centers for Medicare and Medicaid Services (U.S.) Current Procedural Terminology* Decision Making Diagnosis Electronic Health Records / standards* Health Care Surveys Humans Internship and Residency Medical Audit Medical Record Administrators Practice Management, Medical / economics*, standards* Professional Competence Tennessee United States |
From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine
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