Coding and Billing Education with New Documentation Guidelines: Investigating Orthopedic Provider Confidence and...

In January 2021, the Centers for Medicare and Medicaid Services (CMS) updated outpatient evaluation and management (E/M) coding guidelines, allowing orthopedic providers to choose between medical decision-making (MDM) or time-based billing. Providers can now bill based on the severity of symptoms with MDM or the total time spent on chart review, documentation, and coordinating care with time-based billing. Given the new CMS guidelines, it is necessary to evaluate the impact of these changes on provider confidence and accuracy with E/M billing and assess the implementation utility of coding education with updated guidelines in an effort to increase comfort and accuracy.

This study, conducted in two phases in 2021 and 2023, assessed orthopedic providers' confidence and accuracy with coding under the new CMS guidelines. In the first phase, providers were surveyed on their confidence with different coding levels (Levels 3-5) and comfort using MDM and time-based billing. Providers' coding accuracy performance was measured via monthly coding audits and compared to survey responses. Each provider then participated in one-on-one educational sessions on the new guidelines with a focus on improving their confidence and accuracy. In the second phase, the providers who completed the first survey took a follow-up survey to reassess their comfort and coding accuracy.

We found a significant improvement overall for all providers in confidence across all levels after education, with residents showing the greatest improvement in Levels 3 and 4, and advanced practice providers (APPs) showing the greatest improvement in Level 5 (p < .05). There was a significant decline in comfort with MDM among APPs and attending physicians or providers (i.e., attendings), and a significant increase in comfort with time-based billing among APPs (p < .05). After coding education, accuracy significantly increased for all providers overall (p < .05). By group, only attendings demonstrated a statistically significant increase in accuracy (p < .05). The findings suggest that mandatory education in the setting of new guidelines enhances coding confidence and accuracy but varies among providers, which may be explained by variable financial motivators and familiarity with old guidelines. Subjective confidence was not predictive of objective coding accuracy (p < .05), suggesting that providers may overestimate their coding abilities.

Previous studies have demonstrated that accurate documentation of E/M care significantly improves charge capture and reimbursement. Tailored coding training for providers based on deficiencies identified during coding audits, rather than areas of self-reported weakness, may be implemented to address deficits in coding accuracy, ensuring that all providers can navigate coding and billing effectively, and consequently contribute to better financial outcomes for healthcare systems.