Rajiv B Gala1, Seine Chiang. 1. Department of Obstetrics and Gynecology, Ochsner Clinic Foundation, and The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, LA.
Abstract
BACKGROUND: The goal of this study was to determine how increasing levels of residency training as well as a documentation and coding curriculum affected coding accuracy in the continuity clinic setting. METHODS: All postgraduate year (PGY) 2 through PGY 4 residents (n=22) participated in a mandatory 3-module curriculum. Residents completed mock charge tickets in the obstetrics and gynecology continuity clinic for every patient encountered 1 month before and 1 month after the curriculum. An audit of 5 random charts per resident (n=110) compared chart documentation with the billing levels noted on the mock charge tickets. RESULTS: We found a significant reduction in the number of undercoded charts for everyone except PGY 4 residents. In addition, all residents correctly coded more charts after the curriculum (from 30 to 46 charts, P=0.03). CONCLUSION: The first phase of our documentation and coding curriculum study demonstrated that significant improvements in coding accuracy are achieved when implemented among PGY 2 and PGY 3 residents. Refinements in the basic foundation of knowledge may help prevent overcoding errors.
BACKGROUND: The goal of this study was to determine how increasing levels of residency training as well as a documentation and coding curriculum affected coding accuracy in the continuity clinic setting. METHODS: All postgraduate year (PGY) 2 through PGY 4 residents (n=22) participated in a mandatory 3-module curriculum. Residents completed mock charge tickets in the obstetrics and gynecology continuity clinic for every patient encountered 1 month before and 1 month after the curriculum. An audit of 5 random charts per resident (n=110) compared chart documentation with the billing levels noted on the mock charge tickets. RESULTS: We found a significant reduction in the number of undercoded charts for everyone except PGY 4 residents. In addition, all residents correctly coded more charts after the curriculum (from 30 to 46 charts, P=0.03). CONCLUSION: The first phase of our documentation and coding curriculum study demonstrated that significant improvements in coding accuracy are achieved when implemented among PGY 2 and PGY 3 residents. Refinements in the basic foundation of knowledge may help prevent overcoding errors.
Entities:
Keywords:
Coding; documentation; evaluation and management; systems-based practice
Authors: Morhaf Al Achkar; Seema Kengeri-Srikantiah; Biniyam M Yamane; Jomil Villasmil; Michael E Busha; Kevin B Gebke Journal: BMC Med Educ Date: 2018-06-13 Impact factor: 2.463