Resident Education of Documentation and Coding

Abstract

Objective: 1) Develop resident billing/coding education based on a needs-based assessment; 2) Expand systems-based practice competency; 3) Empower residents with a broader skill set; 4) Minimize risk exposure via adequate documentation; 5) Examine resident billing practices and estimate potential billing errors.

Method: A sample of residents and attendings from our otolaryngology program were administered a pretest/written survey on knowledge/opinions of documentation and coding for physician services. Responses were used to create multi-modality educational intervention. Resident billing was used to assess pre/post-intervention ability to bill for physician services in an outpatient clinic setting.

Results: A total of 12 out of 13 staff reported that residents did not demonstrate ability to document and code. No residents currently perform billing, but 12 of 14 assume that they will be in the future. All the residents believed billing training was useful, although 2 did not think it should be taught during residency. A total of 17% of 60 pre-intervention encounters were accurately coded. A total of 68% of total encounters resulted in underbilling by an average of $22/encounter and 15% of total encounters resulted in overbilling by an average of $35/encounter. Total lost charges across all encounters were estimated at $909.00 due to inappropriate coding and $710.00 due to insufficient documentation.

Conclusion: Residents are not currently educated regarding documentation and coding for physician services. Therefore, they have a limited understanding of documentation/coding for physician services as evidenced by inaccurate shadow billing. All residents acknowledge that this topic is important to their career with a majority of them interested in learning this information while in residency training.