Pediatric Chart Accuracy

PCC's A1 Coding Resource, Jan, shared with me some interesting data today.  She has kept track of her chart audits dating back to 2008 and wondered what the results looked like.  The E&M results are fascinating.

41% of the charts match her analysis.  The practice said 99213 and the notes supported it.

12% of the time, the notes supported a higher code.  The doctor scratched 99213 on the superbill (or clicked in the EHR) and it could have been a 99214.

Those of you who can do fast math know what's next.

47% of the claims were over-coded.  The doctors said 99214 and the chart note only supports a 99213.  Or 99212.

Our sample size is not large or consistent enough to see if there has been a trend over time.  The data also involves multiple EHRs (almost none PCC's) and a lot of paper charts.  I can't identify any variables that affect the results, I can only say that there aren't just a few bad practices kicking these numbers out of whack.  It's everyone.

When the is last time you had a chart audit?