Original ReportsImproving Orthopedic Resident Knowledge of Documentation, Coding, and Medicare Fraud
Introduction
Incorrect or incomplete documentation and coding for physician services has detrimental effects on the entire health care system. Upcoding by physicians is known to cost the Centers for Medicare and Medicaid Services up to billions each year in resource use and improper payments.1 On the contrary, downcoding services risks compromising the financial viability of many private practices and academic training centers.2 Moreover, both the former and the latter are, by definition, fraudulent coding acts which ultimately are subject to legal ramifications.3
Physicians are looked to as pivotal leaders in the fight against rising health care costs. Although this concept is intuitive, the notion that physicians receive little (if any) training in the basics of proper documentation, billing, and coding while in medical school, residency, and fellowship remains a topic receiving relatively little attention until the last decade.4, 5, 6, 7 In 2006, a survey of graduating orthopedic residents revealed that >90% felt that formal training in documentation and coding was necessary during residency, and only 13% stated that they felt confident in their ability to start coding by their first day as a new attending.8 A 2014 pilot study comparing resident and attending current procedural terminology (CPT) coding for foot and ankle surgeries found that resident and attending CPT codes were the same for only 42% of surgeries, and the residents had been using incorrect CPT codes for logging cases.9 A 2015 survey of 182 practicing orthopedic surgeons demonstrated that the average overall self-rated level of business knowledge at the conclusion of residency was only 2.4 on a 10-point scale (1 = “knew nothing at all”, 10 = “complete understanding”). In addition, after factoring in different subcategories which were all weighted based on level of clinical importance, the 2 areas with the greatest functional deficits were “business operations” and “billing/coding.”10
Beyond orthopedics, residents and physicians in all specialties report the same generalized findings11, 12, 13, 14, 15, 16, 17, 18, 19: first, there is an educational deficit in teaching residents and fellows the proper documentation and coding basics. Second, these educational and training deficits have persisted despite the evolving health care environment which now requires increasing levels of physician interaction with multiple health care entities, including insurance companies and hospitals. Finally, the vast majority of new attending’s report that they feel unprepared and inadequately trained in these areas, and physicians are becoming increasingly vulnerable with heightened levels of scrutiny toward a physician’s documentation, coding, and billing practices in the transparent age of the electronic health record (EHR).
Addressing the deficit poses a significant challenge in the setting of significant barriers to implementation.4, 13, 14 Surgical residency programs in particular are under a significant amount of pressure to meet increasing requirements in surgical skills assessed and required case volume numbers while maintaining duty-hour restrictions. Thus, these barriers have tempered the increasing demand expressed by all levels in the residency program educational hierarchy, and widespread incorporation of these topics into the training curriculum is most likely to be achieved in an educational format that is concise, effective, and uses very little resources.
The purpose of this study was 2-fold: first, we wished to assess a group of orthopedic residents’ fund of knowledge regarding basic clinical documentation guidelines, coding principles, and self-perceived level of comfort in these areas. Second, we analyzed a single, high-yield educational session’s effect on orthopedic resident knowledge acquisition and awareness of these concepts.
Section snippets
Materials and Methods
Institutional review board approval was obtained before executing this study. Orthopedic residents voluntarily and anonymously participated in a 24-point baseline assessment examination comprised of questions testing basic documentation and coding principles. Questions ranged from the fundamental components of assigning a code for evaluation and management services to various general concepts testing surgical coding, procedural “bundling,” and knowledge of Medicare fraud. At the end of the
Results
In total, 32 orthopedic residents completed the teaching sessions. A full breakdown of residents by PGY-level composition mix and examination scores at both sites is provided in Table 1. None of the residents had any prior formal education in documentation and coding. There was a statistically significant improvement in all resident individual total scores on the 24-point examination when comparing the baseline and postsession scores (p = 0.020) (Table 1). When separated out by PGY-levels, the
Discussion
Our study adds to the existing body of literature demonstrating resident training deficiencies in teaching documentation and coding principles. Furthermore, to our knowledge this is the only study reporting to not only achieve significant improvement in resident knowledge acquisition of these concepts in less than an hour, but also doing so without the use of a coding specialist for the education. One other previous study reported similar improvement after a 90-minute session directed by a
Conclusion
The educational session presented in this study can serve as a focused and efficient addition to any existing residency or fellowship curriculum of study. We demonstrated that this was reproducible at 2 separate sites with similar groups of participating orthopedic residents encompassing all levels of training.
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