Expert agreement in Current Procedural Terminology evaluation and management coding.
BACKGROUND
Available data suggest that physicians are accurate in approximately 55% of Current Procedural Terminology (CPT) evaluation and management (E/M) coding for their services. This accuracy is relative to observers' or auditors' assigned codes for these services, a group that has not been studied for their consistency in application of the CPT E/M coding guidelines. The purpose of this study was to determine the level of agreement of certified coding specialists in their application of CPT E/M coding guidelines.


METHODS
Three hundred certified professional coding specialists randomly selected from the active membership of the American Health Information Management Association were sent 6 hypothetical progress notes of office visits along with a demographic survey. The study group assigned CPT E/M codes to each of the progress notes and completed the demographic survey.


RESULTS
Coding specialists agreed on the CPT E/M codes for 57% of these 6 cases. The level of agreement for the individual cases ranged from 50% to 71%. Relative to the most common or consensus code, undercoding of established patients occurred more commonly than overcoding. In contrast, for new patient progress notes, overcoding relative to the consensus code was more common than undercoding.


CONCLUSIONS
There is substantial disagreement among coding specialists in application of the CPT E/M coding guidelines. The results of this study are similar to results of prior studies assessing physician coding accuracy, suggesting that the CPT coding guidelines are too complex and subjective to be applied consistently by coding specialists or physicians.
King
Mitchell S
MS
Department of Family medicine, Northwestern University Medical School, Chicago, IL, USA. m-king1@nwu.edu
Lipsky
Martin S
MS
Sharp
Lisa
L
D000328:Adult; D000368:Aged; D005069:Evaluation Studies as Topic; D005260:Female; D005568:Forms and Records Control / Q000592:standards*; D017408:Guidelines as Topic; D019538:Health Care Surveys; D006801:Humans; D008297:Male; D008499:Medical Records / Q000145:classification*; D008875:Middle Aged; D011216:Practice Management, Medical / Q000592:standards*; D011361:Professional Competence; D012680:Sensitivity and Specificity; D009626:Terminology as Topic; D013812:Therapeutics / Q000145:classification*; D014481:United States