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Related Experiment Videos

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

Kimeya F Ghaderi1, Scott T Schmidt2, Brian C Drolet3

  • 1Department of Medicine, MedStar Harbor Hospital, Baltimore, Maryland.

Journal of Surgical Education
|September 22, 2016
PubMed
Summary

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This summary is machine-generated.

Surgical residents improved outpatient coding and billing accuracy through targeted education and workflow changes. This led to a significant increase in higher-level evaluation and management (E&M) codes, enhancing documentation quality.

Area of Science:

  • Medical Education
  • Health Systems & Management
  • Surgical Residency Training

Background:

  • Limited understanding of coding and billing among surgical residents despite emphasis on systems-based practice.
  • Need for improved documentation and coding in outpatient surgical encounters.

Purpose of the Study:

  • To develop and assess a multifaceted intervention to enhance surgical residents' knowledge and performance in outpatient coding and billing.
  • To measure the impact of educational and workflow interventions on resident documentation and coding practices.

Main Methods:

  • A cohort of 12 surgical residents participated in educational and workflow interventions at a tertiary care center's outpatient clinic.
  • Billing data from 1285 pre-intervention encounters (FY2012) and 1170 post-intervention encounters (FY2013) were compared.
Keywords:
Practice-Based Learning and ImprovementSystems-Based Practicecoding and billingevaluation and management codesresident educationsystems-based practice

Related Experiment Videos

  • Study-blinded auditors verified all documentation and coding for accuracy.

    • Main Results:

    • A significant and sustained increase in billing with supporting clinical documentation was observed post-intervention.
    • The average monthly evaluation and management (E&M) code level for established patients rose from 2.14 to 3.05 (p < 0.01).
    • The average monthly E&M code level for new patients increased from 2.61 to 3.19 (p < 0.01).

    Conclusions:

    • Educational and workflow interventions effectively improved surgical residents' coding and billing for outpatient encounters.
    • Externally audited data confirmed significantly higher rates of complex E&M coding post-intervention.
    • Improved resident awareness of documentation and billing practices led to better coding outcomes.