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The impact of a documentation and coding curriculum in an obstetrics and gynecology continuity clinic
1Department of Obstetrics and Gynecology, Ochsner Clinic Foundation, and The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA.
Background:
The goal of this study was to determine how increasing levels of residency training as well as a documentation and coding curriculum affected coding accuracy in the continuity clinic setting.
Methods:
All postgraduate year (PGY) 2 through PGY 4 residents (n=22) participated in a mandatory 3-module curriculum. Residents completed mock charge tickets in the obstetrics and gynecology continuity clinic for every patient encountered 1 month before and 1 month after the curriculum. An audit of 5 random charts per resident (n=110) compared chart documentation with the billing levels noted on the mock charge tickets.
Results:
We found a significant reduction in the number of undercoded charts for everyone except PGY 4 residents. In addition, all residents correctly coded more charts after the curriculum (from 30 to 46 charts, P=0.03).
Conclusion:
The first phase of our documentation and coding curriculum study demonstrated that significant improvements in coding accuracy are achieved when implemented among PGY 2 and PGY 3 residents. Refinements in the basic foundation of knowledge may help prevent overcoding errors.
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