Describing Congruence Between Procedural Codes and Medical Record Text in Veterans Health Administration Chiropractic Notes.

Objective: The purpose of this study was to describe congruence between Current Procedural Terminology (CPT) codes and text documentation of therapeutic procedures from chiropractic notes in the Veterans Health Administration (VHA).

Methods: A manual chart review of national electronic health record data was performed. We randomly sampled 1000 on-station VHA chiropractic visits occurring from October 1, 2017 to September 30, 2018 among patients lacking such visits within the prior 12 months. CPT and documented text procedures were extracted. We excluded evaluation and management codes and mapped only therapeutic procedures to 6 categories. Utilizing a novel rating system evaluating congruence between CPT and procedures recorded in text, 2 analyses were performed based upon the inclusion or exclusion of patient education codes.

Results: CPT data from 808 included notes were abstracted and analyzed. Of these, 239 (29.6%) were rated completely congruent, and 513 (63.5%) partially congruent. In an analysis of 790 notes from which patient education CPT codes were excluded, 404 (51.1%) were completely congruent and 329 (41.4%) partially congruent.

Conclusion: Congruence between CPT coding and text documentation of therapeutic procedures in VHA chiropractic initial visits was generally high. Areas of variable congruence, especially the low presence of patient education codes, highlight the limitations in using CPT codes alone to describe VHA chiropractic care.