The Documentation-Coding Connection: CPT-4 coding inconsistent; templates could help

CPT-4 coding inconsistent; templates could help

Agreement in coding of emergency charts between coding agencies used by one hospital system was only poor to fair, and the distribution of assigned CPT-4 codes was significantly different among the agencies, according to a study from William Beaumont Hospital System in Royal Oak, MI, published in the Annals of Emergency Medicine (Bentley PN, Wilson AG, Derwin ME, et al. Reliability of assigning correct current procedural terminology-4 E/M codes. Ann Emerg Med 2002; 40:269-274).

The researchers did three prospective trials, with two interagency audits and one intra-agency audit. In addition to poor agreement in coding, they found that the distribution of CPT-4 codes was significantly different in each group.

"We find this latter observation startling and disturbing, and if generalizable, this will have important economic and legal ramifications," they wrote, pointing to the possibility of prosecution for billing fraud. They suggested the following solutions:

• using templates to reduce variation of documentation;
• requiring more rigorous formatting of dictations for more consistent documentation;
• performing a more thorough review of documentation guidelines provided by the Centers for Medicaid & Medicare Services (CMS) for use in assigning CPT codes.

(Editor’s note: The guidelines can be downloaded at no charge at the CMS web site: http://cms.hhs.gov. Click on "Medicare" and "Documentation Guidelines for Evaluation and Management Services.")