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

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.

Management of gestational diabetes by family physicians and obstetricians.

BACKGROUND: Studies suggest that there are differences between family physicians' (FPs) and obstetricians' (OBs) management of women with low-risk pregnancies. This study was conducted to examine outcomes in women with gestational diabetes mellitus (GDM) to see if similar patterns exist between those cared for by FPs and those cared for by OBs. METHODS: A retrospective chart review was undertaken and analyzed by prenatal care provider. Eight hundred thirteen women were identified as having a pregnancy complicated by GDM. Management outcome data of FPs and OBs were compared. RESULTS: Eighteen percent of patients were cared for by FPs. The percentage with a prior history of GDM did not differ between groups. Patient groups were similar demographically except that FPs cared for a significantly higher percentage of patients on public assistance (60% vs 38%, P < .001). Average prepregnancy weight and body mass index were equal, as were average weight gain, gestational week at entrance to care, and number of prenatal visits. Class instruction on diabetes was given to 83% of FP patients and 85% of OB patients. A greater percentage of OB patients were placed on insulin therapy (33% vs 24%, P < .05). Complications of pregnancy, labor, and delivery were equal, but a higher number of OB patients had a cesarean section (33% vs 11% for FPs). Despite the equal occurrence of preterm labor/delivery and low birthweight, OBs used tocolysis in significantly more women than did FPs (10.3% vs 4.7%, P < .03). Average birthweight of infants delivered by FPs and OBs (3259 g and 3356 g, respectively), macrosomia rate (12% and 13%, respectively), length of pregnancy, fetal complication rate, Apgar scores, and length of hospital stays were all equivalent. CONCLUSIONS: Although there are variations in the care of women whose pregnancy is complicated by gestational diabetes mellitus, there are no significant differences in neonatal outcome. There is, however, an overall lower rate of both cesarean section and tocolysis use among women cared for by FPs.