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

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.

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.

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

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

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).

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.