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

J Fam Pract. 2000 Jul;49(7):642-5.


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.

Publication types

  • Comparative Study

MeSH terms

  • Ambulatory Care / classification*
  • Ambulatory Care / economics
  • Centers for Medicare and Medicaid Services, U.S.
  • Documentation / standards*
  • Faculty, Medical / standards
  • Family Practice / economics
  • Family Practice / standards*
  • Forms and Records Control / standards
  • Guidelines as Topic*
  • Humans
  • Insurance Claim Reporting / classification*
  • Insurance Claim Reporting / standards
  • Internship and Residency / standards
  • Medical Audit
  • Observer Variation
  • Office Visits*
  • Patient Credit and Collection / standards
  • Terminology as Topic
  • United States