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首页> 外文期刊>Archives of family medicine >Evaluation and management services. A comparison of medical record documentation with actual billing in community family practice.
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Evaluation and management services. A comparison of medical record documentation with actual billing in community family practice.

机译：评估和管理服务。社区家庭实践中病历文档与实际账单的比较。

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OBJECTIVE: To compare the concordance of family physicians' billing for evaluation and management services with medical record documentation. DESIGN: Multi-method, cross-sectional observation study. SETTING: Eighty-four family practices in northeast Ohio. PARTICIPANTS: Four thousand fifty-four outpatients visiting 138 family physicians. MAIN OUTCOME MEASURE: The degree of concordance between evaluation and management Current Procedural Terminology codes billed by physicians, with those codes assigned by trained research nurses using American Medical Association criteria to code medical records for the same visits. RESULTS: Discrepancies between the multifactorial nature of family practice outpatient visits and the Current Procedural Terminology coding criteria, which dictate overcoding for depth rather than breadth, made coding difficult (multiple-rater kappa statistic between research nurses = 0.36). Among 4137 outpatient visits with complete billing information, 57% of the Current Procedural Terminology codes generated by medical record review were concordant with the actual billing code assigned by physicians. Undercoding and overcoding occurred at a similar frequency (21% and 19%, respectively) and differed by more than 1 code in fewer than 4% of visits. Visits by new patients were more likely to be inaccurately coded than visits by established patients. CONCLUSIONS: Record documentation by community family physicians largely reflects the level of services billed using evaluation and management codes. Undercoding is as common as overcoding. Efforts from regulatory agencies should be redirected from penalizing physicians for overcoding to focusing on the development of coding criteria that reflect the multifactorial nature of outpatient primary care practice.
机译：目的：比较家庭医生在评估和管理服务方面的账单与病历文档的一致性。设计：多方法，横断面观察研究。地点：俄亥俄州东北部的84个家庭实践。参与者：454位门诊患者拜访了138位家庭医生。主要观察指标：评估与管理之间由医生计费的现行程序术语代码与由训练有素的研究护士根据美国医学协会的标准分配的代码一致的程度。结果：家庭门诊就诊的多因素性质与现行程序术语编码标准之间存在差异，该标准指示对深度而非宽度进行超编码，从而使编码变得困难（研究护士之间的多评估人kappa统计= 0.36）。在4137个具有完整账单信息的门诊就诊中，由病历审查生成的当前程序术语代码中的57％与医师分配的实际账单代码一致。欠编码和过编码的发生频率相似（分别为21％和19％），并且在不到4％的访问中相差超过1个代码。新患者的访问比已建立患者的访问更有可能编码不正确。结论：社区家庭医生的记录文件在很大程度上反映了使用评估和管理代码计费的服务水平。欠编码与过编码一样普遍。应当将监管机构的工作从惩罚过度编码的医生转移到关注反映门诊初级保健实践的多因素性质的编码标准的开发上。

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