Teaching residents coding and documentation: effectiveness of a problem-oriented approach

Implementation of a Business of Healthcare Curriculum for General Surgery Residents

OBJECTIVE

To better prepare general surgery residents for handling the business aspects of healthcare, this project evaluation reports on the implementation of a business of healthcare curriculum (BHC) in a general surgery residency program. We evaluated (pre and post curriculum) self-perceived knowledge and attitudes toward common business topics.

DESIGN

General surgery residents were administered a 13-item survey (7 Likert-type and 3 open-ended items assessing self-perceived knowledge and attitudes toward BHC, and 3 demographic questions) prior to the start of the curriculum. The curriculum was comprised of four core sessions, which included didactic lectures and group projects, including the creation of a business plan. At the conclusion of the curriculum, a post-test with the same items was administered. A total of 21 residents completed both the pre and post-tests.

SETTING

The BHC was a mandatory part of the general surgery residency program and was conducted in Honolulu, Hawaii (University of Hawaii at Manoa).

PARTICIPANTS

All general surgery residents, PGY-1 to PGY-5, were required to participate in the curriculum.

RESULTS

Statistically significant increases in resident knowledge were found overall and specifically for healthcare reform legislation, differences between practice settings, financial matters, contracting and coding and billing for services. Additionally, responses to open-ended questions showed that residents had a positive attitude toward the curriculum and found it useful.

CONCLUSIONS

General surgery residency programs can successfully create an impactful business of healthcare curriculum with minimal cost if volunteers and existing resources are utilized.

The impact of an otolaryngology inpatient consult documentation improvement program

Objective

In an era of limited medical training funds and challenges for teaching centers to maintain their academic mission, the importance of accurate documentation to ensure commensurate coding and billing for services is critical. We sought to develop a practical program that would teach residents documentation skills with the goal of more accurately capturing the work being done in a tertiary care academic medical center.

Methods

A case-control study was performed. Otolaryngology inpatient and Emergency Department consultation notes at a single tertiary medical center were reviewed and knowledge gaps and shortcomings in documentation identified. Three short educational sessions were provided on documentation skills. During the same timeframe, templates in the electronic medical record were standardized to help maintain thoroughness of documentation within the consultation note.

Results

A total of 1476 consultations performed by the Otolaryngology department during a 9-month period in FY17/18 (preintervention) were compared to a total of 1622 consultations performed during the same 9-month period in FY19/20 (postintervention). The percent of billable consultations increased from 42.4% to 50.9% (p < .001). Similarly, the percentage of consultations coding at a higher level of complexity rose from 51.6% to 59.5% (p = .002). This improvement led to an increase in consultation charges of more than $130,000.

Conclusion

This study demonstrates that a simple documentation and coding curriculum and workflow interventions can lead to more thorough and improved consult documentation as evidenced by a significant increase in the percentage and complexity of billable Otolaryngology consultations at a tertiary academic center.

Level of Evidence

4.

Impact of Coding Curriculum on Dermatology Resident Billing

Background

Competent medical coding is key to maintaining a successful dermatology practice. Resident billing performance can have significant financial implications for the academic institutions employing them. During their residency training, dermatology residents commonly find themselves responsible for the billing of patient encounters. However, despite the importance of adequate knowledge and skill in medical coding, recent data show inadequacies in this aspect of resident education. The goal of this study is to evaluate the impact of an interventional coding curriculum on dermatology residents’ billing accuracy at our institution.

Methodology

Billing data, including evaluation and management (E/M) level of service, procedural codes, and current procedural terminology modifiers (if applicable) were queried from the electronic medical records (EMR) at a resident clinic seeing patients on three half-days each week. Billing codes were gathered from patient visits occurring in two separate time periods, before and after the intervention. The intervention consisted of monthly resident lectures on E/M and procedural billing in outpatient dermatology with associated quizzes. Billing accuracy was verified by three attending dermatologists through chart review and compared between the two time periods.

Results

Overall, billing data from 532 patient visits, 267 from the pre-intervention period and 265 from the post-intervention period, were checked for accuracy. The accuracy of resident-billed E/M levels of service was similar between the pre- and post-intervention periods (44.3% vs. 44.8%). Similar rates of undercoding and overcoding were noted between the pre- and post-intervention periods (35.2% undercoded and 8% overcoded vs. 35.7% and 8.9%, respectively). However, substantial improvements were noted in the rate of errors with procedural codes and modifiers in the post-intervention period. Overall, 21.9% of procedural codes were incorrectly billed pre-intervention compared to 3.7% post-intervention (p < 0.05). Moreover, 55.2% of modifiers were incorrectly billed pre-intervention versus 27.3% post-intervention (p < 0.05).

Conclusions

Our analysis suggests that billing lectures yielded a clear improvement in resident billing accuracy at our institution. While there was no improvement in E/M coding, there was a significant improvement in the usage of procedural codes and modifiers. Similar analyses can be used by other residency programs to monitor resident billing performance and the efficacy of educational programs on medical billing.

Trends in Apical Suspension at the Time of Hysterectomy for Pelvic Organ Prolapse: Impact of American College of Obstetricians and Gynecologists Recommendations

OBJECTIVE

The aim of the study was to compare national surgical practice patterns of performing apical suspension procedures (ASPs) at the time of hysterectomy for pelvic organ prolapse (POP) before and after the publication of the American College of Obstetricians and Gynecologists (ACOG) 2017 Practice Bulletin on POP.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried for hysterectomy cases performed for POP indications for the years 2015-2016 and 2018-2019. The primary outcome was the use of ASP at the time of hysterectomy for POP. Secondary outcomes included the use of anterior, posterior, and paravaginal prolapse repair procedures. Multivariable regression analysis was performed to identify factors associated with performing a hysterectomy without an ASP.

RESULTS

A total of 11,336 cases were included, and apical prolapse was the primary POP diagnosis in 86.3% of these cases. There was no statistically significant change in the utilization of ASPs in 2018-2019 compared with 2015-2016 (51.4% vs 49.8%, P = 0.081). Urogynecologists were significantly more likely than general gynecologists to perform ASPs (65.6% vs 37.5%, P < 0.001), which was confirmed on multivariable logistic regression analysis (adjusted odds ratio, 3.257; P < 0.001). The use of concomitant anterior repairs (44.1% vs 39.5%, P < 0.001) and posterior repairs (47.5% vs 41.3%, P < 0.001) increased in the 2018-2019 cohort.

CONCLUSIONS

There was no overall increase in the utilization of concomitant ASPs at the time of hysterectomy done for POP indications despite the 2017 American College of Obstetricians and Gynecologists practice bulletin. Urogynecologists were more likely to perform ASPs than general gynecologists.

Assessing the quality of electronic medical records as a platform for resident education

BACKGROUND

Previous studies have assessed note quality and the use of electronic medical record (EMR) as a part of medical training. However, a generalized and user-friendly note quality assessment tool is required for quick clinical assessment. We held a medical record writing competition and developed a checklist for assessing the note quality of participants' medical records. Using the checklist, this study aims to explore note quality between residents of different specialties and offer pedagogical implications.

METHODS

The authors created an inpatient checklist that examined fundamental EMR requirements through six note types and twenty items. A total of 149 records created by residents from 32 departments/stations were randomly selected. Seven senior physicians rated the EMRs using a checklist. Medical records were grouped as general medicine, surgery, paediatric, obstetrics and gynaecology, and other departments. The overall and group performances were analysed using analysis of variance (ANOVA).

RESULTS

Overall performance was rated as fair to good. Regarding the six note types, discharge notes (0.81) gained the highest scores, followed by admission notes (0.79), problem list (0.73), overall performance (0.73), progress notes (0.71), and weekly summaries (0.66). Among the five groups, other departments (80.20) had the highest total score, followed by obstetrics and gynaecology (78.02), paediatrics (77.47), general medicine (75.58), and surgery (73.92).

CONCLUSIONS

This study suggested that duplication in medical notes and the documentation abilities of residents affect the quality of medical records in different departments. Further research is required to apply the insights obtained in this study to improve the quality of notes and, thereby, the effectiveness of resident training.

Influence of an educational review sheet on chiropractic students' evaluation and management coding performance: A randomized trial

OBJECTIVE

To evaluate whether an educational worksheet would influence the accuracy of simulated evaluation and management (E/M) coding among students in a doctor of chiropractic program.

METHODS

An educational worksheet was developed as well as a test and survey involving simulated patient scenarios. Two groups were analyzed in this project. All members of the intervention group received the educational worksheet and were able to use it while completing their E/M coding test and survey; the control group completed their E/M coding test and survey without the educational worksheet. The E/M coding test and survey were scored for each group; the mean group scores were evaluated, and between group differences were analyzed using a 2-tailed t test.

RESULTS

The intervention group recorded significantly higher scores (p < .001) on the E/M coding test and survey.

CONCLUSION

Doctor of chiropractic students who were provided with an E/M educational worksheet had fewer errors on a simulated E/M coding test and survey.

Coding Discrepancies Between Medical Student and Physician Documentation

OBJECTIVE

Accurate medical documentation is a core competency in medical education and is critical to successful surgical practice. The following study aims to assess the coding accuracy of medical student documentation.

DESIGN

Retrospective chart review identified patient encounters in a surgery clinic that contained documentation by both a faculty member and a third-year medical student. Records were de-identified and assigned a level of service (LOS) and diagnostic code by trained, expert coders. Differences in LOS and diagnostic code were then compared between medical student and faculty documentation.

SETTING

A single academic health system.

PARTICIPANTS

Third-year medical students.

RESULTS

80 full patient evaluations and 20 postoperative visits were analyzed. Median faculty and student LOS was 4 (range 3-4) and 3 (range 0-4) respectively (p < 0.001). Students failed to document a sufficient number of elements in the evaluation, failed to specify studies ordered, and documented low medical decision making. Diagnostic code was concordant between students and faculty for only 31% of documentation.

CONCLUSION

Student documentation of clinical encounters is coded at a lower LOS than faculty documentation. These results likely reflect the lack of education regarding E/M coding in medical school, which is integral to real world practice.

SUMMARY

Accurate medical documentation is critical to the correct diagnostic coding and billing of a medical encounter. We found that compared to faculty documentation of the same patient evaluations, student documentation was typically coded at a lower level of service and assigned a different diagnostic code by professional medical coders. Addressing these topics in medical school may better prepare students for real-world practice.

Coding and Billing in Surgical Education: A Systems-Based Practice Education Program

OBJECTIVE

Despite increased emphasis on systems-based practice through the Accreditation Council for Graduate Medical Education core competencies, few studies have examined what surgical residents know about coding and billing. We sought to create and measure the effectiveness of a multifaceted approach to improving resident knowledge and performance of documenting and coding outpatient encounters.

DESIGN

We identified knowledge gaps and barriers to documentation and coding in the outpatient setting. We implemented a series of educational and workflow interventions with a group of 12 residents in a surgical clinic at a tertiary care center. To measure the effect of this program, we compared billing codes for 1 year before intervention (FY2012) to prospectively collected data from the postintervention period (FY2013). All related documentation and coding were verified by study-blinded auditors.

SETTING

Interventions took place at the outpatient surgical clinic at Rhode Island Hospital, a tertiary-care center.

PARTICIPANTS

A cohort of 12 plastic surgery residents ranging from postgraduate year 2 through postgraduate year 6 participated in the interventional sequence.

RESULTS

A total of 1285 patient encounters in the preintervention group were compared with 1170 encounters in the postintervention group. Using evaluation and management codes (E&M) as a measure of documentation and coding, we demonstrated a significant and durable increase in billing with supporting clinical documentation after the intervention. For established patient visits, the monthly average E&M code level increased from 2.14 to 3.05 (p < 0.01); for new patients the monthly average E&M level increased from 2.61 to 3.19 (p < 0.01).

CONCLUSIONS

This study describes a series of educational and workflow interventions, which improved resident coding and billing of outpatient clinic encounters. Using externally audited coding data, we demonstrate significantly increased rates of higher complexity E&M coding in a stable patient population based on improved documentation and billing awareness by the residents.

Ethical and educational considerations in coding hand surgeries

PURPOSE

To assess treatment coding knowledge and practices among residents, fellows, and attending hand surgeons.

METHODS

Through the use of 6 hypothetical cases, we developed a coding survey to assess coding knowledge and practices. We e-mailed this survey to residents, fellows, and attending hand surgeons. In additionally, we asked 2 professional coders to code these cases.

RESULTS

A total of 71 participants completed the survey out of 134 people to whom the survey was sent (response rate = 53%). We observed marked disparity in codes chosen among surgeons and among professional coders.

CONCLUSIONS

Results of this study indicate that coding knowledge, not just its ethical application, had a major role in coding procedures accurately. Surgical coding is an essential part of a hand surgeon's practice and is not well learned during residency or fellowship. Whereas ethical issues such as deliberate unbundling and upcoding may have a role in inaccurate coding, lack of knowledge among surgeons and coders has a major role as well.

CLINICAL RELEVANCE

Coding has a critical role in every hand surgery practice. Inconstancies among those polled in this study reveal that an increase in education on coding during training and improvement in the clarity and consistency of the Current Procedural Terminology coding rules themselves are needed.

Level of billing as a function of resident documentation and orthopedic subspecialty at an academic multispecialty orthopedic surgery practice

Documentation, coding, and billing for physician-patient encounters have evolved over time and have significant variability. Appropriate and complete documentation of these encounters can contribute to the financial viability of private and academic medical centers. The objectives of this study were to assess the financial effect of documentation on billing and to compare the authors' institution's distribution of billing level compared with Medicare normative data. Four orthopedic surgery subspecialty clinics were evaluated at a university outpatient clinic over a 1-year period. A single full-day clinic per week was used for each subspecialty. Residents dictated the majority of the reports. All reports were transcribed by medical transcriptionists and coded by certified professional coders. The sports medicine subspecialty generated the highest volume of patient clinic visits, followed by foot and ankle, trauma, and spine (P<.01). The majority of the reports were billed at level 3 (P<.05). Significant differences existed between subspecialty and percentage distribution of billing level (P<.05). Compared with Medicare normative data, a significantly greater percentage of level 3 reports and a lower percentage of level 2 and 4 reports existed in the orthopedic practice (P<.01). The estimated loss of revenue from the fewer level 4 reports was $81,281.11 for 1 year. These findings highlight the need for greater educational interventions to improve provider documentation, coding, and billing. The effect of new electronic medical record systems that prompt providers to include key evaluation and management components will likely affect practices and warrant further analysis.

A reliable billing method for internal medicine resident clinics: financial implications for an academic medical center

BACKGROUND

The financial success of academic medical centers depends largely on appropriate billing for resident-patient encounters. Objectives of this study were to develop an instrument for billing in internal medicine resident clinics, to compare billing practices among junior versus senior residents, and to estimate financial losses from inappropriate resident billing.

METHODS

For this analysis, we randomly selected 100 patient visit notes from a resident outpatient practice. Three coding specialists used an instrument structured on Medicare billing standards to determine appropriate codes, and interrater reliability was assessed. Billing codes were converted to US dollars based on the national Medicare reimbursement list. Inappropriate billing, based on comparisons with coding specialists, was then determined for residents across years of training.

RESULTS

Interrater reliability of Current Procedural Terminology components was excellent, with κ ranging from 0.76 for examination to 0.94 for diagnosis. Of the encounters in the study, 55% were underbilled by an average of $45.26 per encounter, and 18% were overbilled by an average of $51.29 per encounter. The percentages of appropriately coded notes were 16.1% for postgraduate year (PGY) 1, 26.8% for PGY-2, and 39.3% for PGY-3 residents (P < .05). Underbilling was 74.2% for PGY-1, 48.8% for PGY-2, and 42.9% for PGY-3 residents (P < .01). There was significantly less overbilling among PGY-1 residents compared with PGY-2 and PGY-3 residents (9.7% versus 24.4% and 17.9%, respectively; P < .05).

CONCLUSIONS

Our study reports a reliable method for assessing billing in internal medicine resident clinics. It exposed large financial losses, which were attributable to junior residents more than senior residents. The findings highlight the need for educational interventions to improve resident coding and billing.

Preliminary development of the physician documentation quality instrument

OBJECTIVES

This study sought to design and validate a reliable instrument to assess the quality of physician documentation.

DESIGN

Adjectives describing clinician attitudes about high-quality clinical documentation were gathered through literature review, assessed by clinical experts, and transformed into a semantic differential scale. Using the scale, physicians and nurse practitioners scored the importance of the adjectives for describing quality in three note types: admission, progress, and discharge notes. Psychometric methods including exploratory factor analysis were applied to provide preliminary evidence for the construct validity and internal consistency reliability.

RESULTS

A 22-item Physician Documentation Quality Instrument (PDQI) was developed. Exploratory factor analysis (n = 67 clinician respondents) on three note types resulted in solutions ranging from four (discharge) to six (admission and progress) factors, and explained 65.8% (discharge) to 73% (admission and progress) of the variance. Each factor solution was unique. However, four sets of items consistently factored together across all note types: (1) up-to-date and current; (2) brief, concise, succinct; (3) organized and structured; and (4) correct, comprehensible, consistent. Internal consistency reliabilities were: admission note (factor scales = 0.52-88, overall = 0.86), progress note (factor scales = 0.59-0.84, overall = 0.87), and discharge summary (factor scales = 0.76-0.85, overall = 0.88).

CONCLUSION

The exploratory factor analyses and reliability analyses provide preliminary evidence for the construct validity and internal consistency reliability of the PDQI. Two novel dimensions of the construct for document quality were developed related to form (Well-formed, Compact). Additional work is needed to assess intrarater and interrater reliability of applying of the proposed instrument and to examine the reproducibility of the factors in other samples.