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Optimizing Resident Charge Capture with Disappearing Help Text in Note Templates.

Taylor B Martin1, Douglas S Bell2, Jeffrey A Gornbein3

  • 1Division of Medicine-Pediatrics, Department of Medicine, UCLA Health System, Los Angeles, California, United States.

Applied Clinical Informatics
|November 19, 2024
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Summary

Disappearing help text in electronic health records significantly reduced incorrect Current Procedural Terminology (CPT) code usage by residents. This tool improved evaluation and management (E/M) coding accuracy, decreasing the need for attending physician adjustments.

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Area of Science:

  • Medical Informatics
  • Healthcare Administration
  • Clinical Documentation

Background:

  • Accurate coding for evaluation and management (E/M) services is crucial for healthcare reimbursement and quality assessment.
  • Medical residents often face challenges in selecting the correct Current Procedural Terminology (CPT) codes for E/M services.
  • Standardized note templates are widely used in clinical settings to streamline documentation processes.

Purpose of the Study:

  • To assess the effectiveness of integrated disappearing help text in a standardized note template for improving resident CPT code selection for E/M services.
  • To reduce the frequency of CPT code modifications made by attending physicians, serving as a proxy for resident coding accuracy.

Main Methods:

  • A disappearing help text summarizing E/M coding requirements was embedded into a standardized note template for pediatric urgent care residents.
  • An intervention group (PGY 1 residents) used the template with help text, while a control group (PGY 2-3 residents) used an identical template without help text.
  • The primary outcome measured was the incidence of CPT code changes by attending physicians, analyzed using logistic regression.

Main Results:

  • Residents using the help text demonstrated a significantly lower rate of CPT code changes by attending physicians (22.1% vs. 30.6%).
  • This reduction in CPT code adjustments was consistent across different training levels (PGY 1 and PGY 2-3).
  • Multivariable analysis confirmed that the use of help text was independently associated with a substantial decrease in CPT code modification (OR = 0.28).

Conclusions:

  • The implementation of disappearing help text within resident note templates is a promising strategy for enhancing E/M coding accuracy.
  • This intervention led to a significant reduction in the need for attending physician CPT code adjustments, indicating improved resident performance.
  • The findings suggest broader applicability of such assistive text features for improving clinical documentation and coding in various healthcare settings.