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McCabe ME, Mink R, Turner DA, Boyer DL, Tcharmtchi MH, Werner J, Schneider J, Armijo-Garcia V, Winkler M, Baker D, Mason KE. Best Practices in Medical Documentation: A Curricular Module. Acad Pediatr 2022; 22:1271-1277. [PMID: 35307604 DOI: 10.1016/j.acap.2022.02.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 02/04/2022] [Accepted: 02/08/2022] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To create and validate a checklist for high-quality documentation and pilot a multi-modal, immersive educational module across multiple institutions. We hypothesized that this module would improve knowledge, skills, and attitudes in medical documentation. METHODS Module design was grounded in an established curriculum design framework. We conducted the study across 12 pediatric critical care fellowship programs between September 2017 and January 2018. Workshops were allotted 90 minutes for completion. We utilized a pre-/post- study design to determine the workshop's impact. Changes in knowledge were assessed through pre and post testing. Changes in skills were evaluated with a validated checklist for inclusion of key documentation elements. Changes in attitudes were determined through learner self-assessment RESULTS: 83 of 138 eligible fellows (60%) started the module and 62 of 83 (75%) completed data sets for analysis. Immediate post-testing demonstrated modest statistically significant improvement in knowledge, skills, and attitudes. The workshop was easily disseminated and deployed CONCLUSIONS: This study demonstrates that a multi-modal educational intervention can lead to improvement in medical documentation knowledge, skills, and attitudes in a cohort of PCCM fellows and be easily disseminated for use by other specialties and types of clinicians.
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Affiliation(s)
- Megan E McCabe
- Department of Pediatrics/Division of Pediatric Critical Care Medicine (ME McCabe, D Baker), The Children's Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, NY.
| | - Richard Mink
- Department of Pediatrics/Division of Pediatric Critical Care Medicine (R Mink), Harbor-UCLA Medical Center/The Lundquist Institute, Torrance, Calif
| | - David A Turner
- Department of Pediatrics/Division of Pediatric Critical Care Medicine (DA Turner), Duke University School of Medicine, Durham, NC; The American Board of Pediatrics (DA Turner), Chapel Hill, NC
| | - Donald L Boyer
- Department of Anesthesiology and Critical Care Medicine (DL Boyer), Children's Hospital of Philadelphia/ Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - Mohammad Hossein Tcharmtchi
- Department of Pediatrics/Division of Pediatric Critical Care Medicine (MH Tcharmtchi), Baylor College of Medicine/Texas Children's Hospital, Houston, Tex
| | - Jason Werner
- Department of Pediatrics/Division of Pediatric Critical Care Medicine (J Werner), St. Louis University School of Medicine, St. Louis, Mo
| | - James Schneider
- Department of Pediatrics/Division of Pediatric Critical Care Medicine (J Schneider), Northwell Health/Zucker School of Medicine at Hofstra University, Queens, NY
| | - Veronica Armijo-Garcia
- Department of Pediatrics/Division of Pediatric Critical Care Medicine (V Armijo-Garcia), University of Texas Health Sciences Long School of Medicine, San Antonio, Tex
| | - Margaret Winkler
- Department of Pediatrics/Division of Pediatric Critical Care Medicine (M Winkler), University of Alabama School of Medicine, Birmingham, Ala
| | - David Baker
- Department of Pediatrics/Division of Pediatric Critical Care Medicine (ME McCabe, D Baker), The Children's Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, NY
| | - Katherine E Mason
- Department of Pediatrics/Division of Pediatric Critical Care Medicine (KE Mason), Warren Alpert Medical School of Brown University, Providence, RI
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Gay LJ, Lin D, Colah Z, Raynaldo G. Inpatient Coding System and Opportunities for Documentation Optimization: An Interactive Session for Internal Medicine Residents. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2022; 18:11219. [PMID: 35309253 PMCID: PMC8882690 DOI: 10.15766/mep_2374-8265.11219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 10/31/2021] [Indexed: 06/14/2023]
Abstract
INTRODUCTION The Inpatient Prospective Payment System, the framework for categorization of admissions, is based upon physician documentation leading to International Classification of Diseases, Tenth Revision code generation and Medical Severity Diagnosis-Related Group (MS-DRG) assignment. In this curriculum, we introduced internal medicine residents to this inpatient coding framework and its effects on hospital quality metrics and reimbursement. We focused on educating learners about the importance of physicians being proficient in providing thorough and specific clinical documentation to produce appropriate DRG assignment. METHODS Internal medicine residents participated in a 90-minute session that introduced the basic framework of inpatient coding, discussed effects of physician documentation on hospital quality metrics and reimbursement, and provided tips on opportunities for documentation improvement. In an interactive learning activity, residents were presented with clinical vignettes and earned reimbursement based on their documentation of appropriate diagnoses. Each scenario was followed by clinical definitions and actionable documentation recommendations for common diagnoses. Materials included a PowerPoint presentation, clinical vignettes, sample teaching points, and a rubric to calculate estimated reimbursement. RESULTS Prior to the session, 38% of learners were confident in their understanding of how documentation affects hospital reimbursement, which improved to 90% postsession. Learners reported improvement in their knowledge of documentation requirements for all targeted diagnoses. DISCUSSION This interactive curriculum improved resident knowledge of the inpatient coding system and documentation requirements for common diagnoses and addressed a deficiency in residency education on a topic of significant importance for the success of hospital systems.
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Affiliation(s)
- Lindsey Jordan Gay
- Assistant Professor, Department of Medicine, Baylor College of Medicine and Michael E. DeBakey Department of Veterans Affairs Medical Center
| | - Doris Lin
- Associate Professor, Department of Medicine, Baylor College of Medicine
| | - Ziba Colah
- Fourth-Year Medical Student, Baylor College of Medicine
| | - Glynda Raynaldo
- Assistant Professor, Department of Medicine, Baylor College of Medicine and Michael E. DeBakey Department of Veterans Affairs Medical Center
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Golpira R, Azadmanjir Z, Zarei J, Hashemi N, Meidani Z, Vahedi A, Bakhshandeh H, Fakharian E, Sheikhtaheri A. Evaluation of the implementation of International Classification of Diseases, 11th revision for morbidity coding: Rationale and study protocol. INFORMATICS IN MEDICINE UNLOCKED 2021. [DOI: 10.1016/j.imu.2021.100668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Plawecki AM, Singer MC, Peterson EL, Yaremchuk KL, Deeb RH. Impact of a specialty trained billing team on an academic otolaryngology practice. Am J Otolaryngol 2020; 41:102720. [PMID: 32977062 DOI: 10.1016/j.amjoto.2020.102720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 09/08/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To determine how the incorporation of specialty specific training for coders within a focused billing team affected revenue, efficiency, time to reimbursement, and physician satisfaction in an academic otolaryngology practice. MATERIALS AND METHODS Our academic otolaryngology department recently implemented a new billing system, which incorporated additional training in otolaryngology surgical procedures for medical coders. A mixed model analysis of variance was used to compare billing outcomes for the 6 months before and 6 months after this new approach was initiated. The following metrics were analyzed: Current Procedural Terminology codes, total charges, time between services rendered and billing submission, and time to reimbursement. A survey of department physicians assessing satisfaction with the system was reviewed. RESULTS There were 4087 Current Procedural Terminology codes included in the analysis. In comparing the periods before and after implementation of the new system, statistically significant decreases were found in the mean number of days to coding completion (19.3 to 12.0, respectively, p < 0.001), days to posting of charges (27.0 to 15.2, p < 0.001), days to final reimbursement (54.5 to 27.2, p < 0.001), and days to closure of form (179.2 to 76.6, p < 0.001). Physician satisfaction with communication and coder feedback increased from 36% to 64% after initiation of the new program. CONCLUSIONS The implementation of additional specialty training for medical coders in the otolaryngology department of a large medical system was associated with improved revenue cycle efficiency. Additionally, this model appears to improve physician satisfaction and confidence with the coding system.
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Albano GD, Bertozzi G, Maglietta F, Montana A, Di Mizio G, Esposito M, Mazzeo P, D'Errico S, Salerno M. Medical Records Quality as Prevention Tool for Healthcare-Associated Infections (HAIs) Related Litigation: a Case Series. Curr Pharm Biotechnol 2020; 20:653-657. [PMID: 30961488 DOI: 10.2174/1389201020666190408102221] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 11/27/2018] [Accepted: 12/16/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Healthcare-associated infections are one of the most serious Public Health concern, as they prolong the length of hospitalization, reduce the quality of life, and increase morbidity and mortality. Despite they are not completely avoidable, the number of healthcare-associated infections related to negligence claims has risen over the last years, contributing to remarkable economic and reputation losses of Healthcare System. METHODS In this regard, several studies suggested a key role of medical records quality in determining medical care process, risk management and preventing liability. Clinical documentation should be able to demonstrate that clinicians met their duty of care and did not compromise patient's safety. RESULTS Therefore, it has a key role in assessing healthcare workers' liability in malpractice litigation. Our risk management experience has confirmed the role of medical records accuracy in preventing hospital liability and improving the quality of medical care. CONCLUSION In the presented healthcare-associated infections cases, evidence-based and guidelinesbased practice, as well as a complete/incomplete medical record, have shown to significantly affect the verdict of the judicial court and inclusion/exclusion of hospital liability in healthcare-associated infections related claims.
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Affiliation(s)
- Giuseppe D Albano
- Department of Forensic Pathology, Clinical and Experimental Medicine Department, University of Foggia, Ospedale Colonnello D'Avanzo, Foggia, Italy
| | - Giuseppe Bertozzi
- Department of Forensic Pathology, Clinical and Experimental Medicine Department, University of Foggia, Ospedale Colonnello D'Avanzo, Foggia, Italy
| | - Francesca Maglietta
- Department of Forensic Pathology, Clinical and Experimental Medicine Department, University of Foggia, Ospedale Colonnello D'Avanzo, Foggia, Italy
| | - Angelo Montana
- Department of Medical, Surgical Sciences and Advanced Technologies "G.F. Ingrassia", University of Catania - A.O.U. "Policlinico V. Emanuele", Catania, Italy
| | - Giulio Di Mizio
- Department of Law, University of Catanzaro Magna Graecia, Campus Universitario "S. Venuta", Catanzaro, Italy
| | - Massimiliano Esposito
- Department of Medical, Surgical Sciences and Advanced Technologies "G.F. Ingrassia", University of Catania - A.O.U. "Policlinico V. Emanuele", Catania, Italy
| | - Pietro Mazzeo
- Department of Legal Medicine Azienda ASP, Catania, Italy
| | - Stefano D'Errico
- Department of Legal Medicine Azienda USL Toscana Nordovest, Lucca, Italy
| | - Monica Salerno
- Department of Forensic Pathology, Clinical and Experimental Medicine Department, University of Foggia, Ospedale Colonnello D'Avanzo, Foggia, Italy.,Department of Medical, Surgical Sciences and Advanced Technologies "G.F. Ingrassia", University of Catania - A.O.U. "Policlinico V. Emanuele", Catania, Italy
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Weinberg JA, Chapple KM, Gagliano RA, Israr S, Petersen SR. Back to the Future: Impact of a Paper-Based Admission H&P on Clinical Documentation Improvement at a Level 1 Trauma Center. Am Surg 2019. [DOI: 10.1177/000313481908500625] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Medicare Severity Diagnosis Related Group (MS-DRG) weight, as derived from the MS-DRG assigned at discharge, is in part determined by the physician-documented diagnoses. However, the terminology associated with MS-DRG determination is often not aligned with typical physician language, leading to inaccurate coding and decreased hospital reimbursements. The goal of this study was to evaluate the impact of a diagnosis picklist within a paper-based history and physical examination (H&P) on the average MS-DRG weight and the Case-mix index (CMI). Our trauma center implemented a paper H&P form for trauma patients featuring picklist diagnoses aligned with the MS-DRG terminology and arranged by the physiologic system. To evaluate its impact, we conducted a cohort study using data from our trauma registry between July 2015 and November 2017. Our cohort included 442 (26.0%) paper and 1,261 (74.0%) dictated H&Ps. Average CMI (2.56 vs 2.15) and expected patients ($25,057 vs $19,825) were higher for the paper group ( P < 0.001, P = 0.002). Adjusted regression models demonstrated paper coding to be associated with 0.265 CMI points, translating to an average increase in expected payment of 6.5 per cent per patient. Utilization of a standardized, paper-based H&P template with picklist diagnoses was associated with a higher trauma service CMI and higher expected payments. Preprinted diagnoses that align with the MS-DRG terminology lead to clinical documentation improvement.
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Affiliation(s)
- Jordan A. Weinberg
- Department of Surgery, Dignity Health, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Kristina M. Chapple
- Department of Surgery, Dignity Health, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Ronald A. Gagliano
- Department of Surgery, Dignity Health, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Sharjeel Israr
- Department of Surgery, Dignity Health, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Scott R. Petersen
- Department of Surgery, Dignity Health, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Patel A, Ali A, Lutfi F, Nwosu-lheme A, Markham MJ. An Interactive Multimodality Curriculum Teaching Medicine Residents About Oncologic Documentation and Billing. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2018; 14:10746. [PMID: 30800946 PMCID: PMC6346345 DOI: 10.15766/mep_2374-8265.10746] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 08/02/2018] [Indexed: 05/12/2023]
Abstract
Introduction Physicians recognize the importance of clinical documentation for accuracy of coding and billing, but it is emphasized little in residency curricula, with an even smaller emphasis on oncology-specific documentation. We developed an educational curriculum to teach residents about clinical documentation for cancer patients. Our tool kit includes didactics, simulated history and physical (H&P) documentation, and personal feedback. Methods A preintervention survey was first administered to gauge baseline knowledge. A simulated H&P was developed that required participants to complete their own assessment and plan. We delivered a 25-minute lecture regarding billing and coding along with documentation tips and tricks specific to hematology/oncology. Thereafter, we handed out a second H&P, and participants had to once again complete their own assessment and plan. These H&Ps were graded by three reviewers using a rubric. We then gave residents personalized feedback using the above data and administered a postintervention survey. Results The postintervention survey revealed that 100% of the residents surveyed found this activity helpful, 83% noted that further knowledge of diagnosis codes was helpful to their learning, 100% noted that that this activity taught them to improve documentation, 91% said they were more likely to use cancer-specific diagnoses, and 91% said they would benefit from direct feedback-based education. Discussion Didactic and formal education is more effective when combined with hands-on examples and direct personalized feedback.
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Affiliation(s)
- Arpan Patel
- Hematology/Oncology Fellow, Division of Hematology & Oncology, University of Florida College of Medicine
| | - Azka Ali
- Medical Resident, Department of Medicine, University of Florida College of Medicine
| | - Forat Lutfi
- Medical Resident, Department of Medicine, University of Florida College of Medicine
| | - Adeaze Nwosu-lheme
- Hematology/Oncology Fellow, Division of Hematology & Oncology, Department of Medicine, University of Florida College of Medicine
| | - Merry Jennifer Markham
- Associate Director, Medical Affairs, University of Florida Health Cancer Center
- Associate Professor, Division of Hematology & Oncology, Department of Medicine, University of Florida College of Medicine
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