Improving Orthopedic Resident Knowledge of Documentation, Coding, and Medicare Fraud

Abstract

Background:
Most residency programs still lack formal education and training on the basic clinical documentation and coding principles. Today's physicians are continuously being held to increasing standards for correct coding and documentation, yet little has changed in the residency training curricula to keep pace with these increasing standards. Although there are many barriers to implementing these topics formally, the main concern has been the lack of time and resources. Thus, simple models may have the best chance for success at widespread implementation.

Purpose:
The first goal of the study was to assess a group of orthopedic residents' fund of knowledge regarding basic clinical documentation guidelines, coding principles, and their ability to appropriately identify cases of Medicare fraud. The second goal was to analyze a single, high-yield educational session's effect on overall resident knowledge acquisition and awareness of these concepts.

Subject selection and study protocol:
Orthopedic residents belonging to 1 of 2 separate residency programs voluntarily and anonymously participated. All were asked to complete a baseline assessment examination, followed by attending a 45-minute lecture given by the same orthopedic faculty member who remained blinded to the test questions. Each resident then completed a postsession examination. Each resident was also asked to self-rate his or her documentation and coding level of comfort on a Likert scale (1-5). Statistical significance was set at p < 0.05.

Main findings:
A total of 32 orthopedic residents were participated. Increasing postgraduate year-level of training correlated with higher Likert-scale ratings for self-perceived comfort levels with documentation and coding. However, the baseline examination scores were no different between senior and junior residents (p > 0.20). The high-yield teaching session significantly improved the average total examination scores at both sites (p < 0.01), with overall improvement being similar between the 2 groups (p > 0.10).

Principal conclusions:
The current healthcare environment necessitates better physician awareness regarding clinical documentation guidelines and coding principles. Very few adjustments to incorporate these teachings have been made to most residency training curricula, and the lack of time and resources remains the concern of many surgical programs. We have demonstrated that orthopedic resident knowledge in these important areas drastically improves after a single, high-yield 45-minute teaching session.

Full text

ORIGINAL REPORTS
Improving Orthopedic Resident
Knowledge of Documentation,
Coding, and Medicare Fraud
Matthew A. Varacallo, MD, Michael Wolf, MD, and Martin J. Herman, MD
Department of Orthopaedics, Drexel University, Philadelphia, Pennsylvania
BACKGROUND:
Most residency programs still lack formal
education and training on the basic clinical documentation and
coding principles. Today’s physicians are continuously being
held to increasing standards for correct coding and documenta-
tion, yet little has changed in the residency training curricula to
keep pace with these increasing standards. Although there are
many barriers to implementing these topics formally, the main
concern has been the lack of time and resources. Thus, simple
models may have the best chance for success at widespread
implementation.
PURPOSE:
The first goal of the study was to assess a group
of orthopedic residents’fund of knowledge regarding basic
clinical documentation guidelines, coding principles, and
their ability to appropriately identify cases of Medicare
fraud. The second goal was to analyze a single, high-yield
educational session’s effect on overall resident knowledge
acquisition and awareness of these concepts.
SUBJECT SELECTION AND STUDY PROTOCOL:
Ortho-
pedic residents belonging to 1 of 2 separate residency
programs voluntarily and anonymously participated. All
were asked to complete a baseline assessment examination,
followed by attending a 45-minute lecture given by the
same orthopedic faculty member who remained blinded to
the test questions. Each resident then completed a postsession
examination. Each resident was also asked to self-rate his or
her documentation and coding level of comfort on a Likert
scale (1-5). Statistical significance was set at p o0.05.
MAIN FINDINGS:
A total of 32 orthopedic residents were
participated. Increasing postgraduate year-level of training
correlated with higher Likert-scale ratings for self-perceived
comfort levels with documentation and coding. However,
the baseline examination scores were no different between
senior and junior residents (p 40.20). The high-yield
teaching session significantly improved the average total
examination scores at both sites (p o0.01), with overall
improvement being similar between the 2 groups
(p 40.10).
PRINCIPAL CONCLUSIONS:
The current healthcare
environment necessitates better physician awareness regard-
ing clinical documentation guidelines and coding principles.
Very few adjustments to incorporate these teachings have
been made to most residency training curricula, and the lack
of time and resources remains the concern of many surgical
programs. We have demonstrated that orthopedic resident
knowledge in these important areas drastically improves
after a single, high-yield 45-minute teaching session.
( J Surg Ed 74:794-798.
J
C
2017 Association of Program
Directors in Surgery. Published by Elsevier Inc. All rights
reserved.)
KEY WORDS:
resident documentation, resident coding,
core competencies, Medicare fraud, orthopedic residency,
residency curriculum
COMPETENCIES:
Patient Care, Professionalism, Practice-
Based Learning and Improvement
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 aca-
demic 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
Correspondence: Inquiries to Matt Varacallo, MD, Department of Orthopaedics,
Hahnemann University Hospital, Drexel University, MS 420 245N, 15th St,
Philadelphia, PA 19102; fax: (215) 762-3442; e-mail: orthopedicpapers@gmail.com
794 Journal of Surgical Education 
&
2017 Association of Program Directors in Surgery. Published by
Elsevier Inc. All rights reserved.
1931-7204/$30.00
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remains a topic receiving relatively little attention until the
last decade.
4-7
In 2006, a survey of graduating orthopedic
residents revealed that 490% 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 knowl-
edge at the conclusion of residency was only 2.4 on a 10-
point scale (1 ¼“knew nothing at all”,10¼“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 findings
11-19
: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.
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 documen-
tation 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 examination, the resident
was prompted to self-rate his or her ability to correctly
document and code on a scale from 1 (“novice”)to5
(“expert”).
Next, a 45-minute educational lecture was provided by
an orthopedic faculty member. The faculty member was
blinded to the test questions given to the residents and the
residents were not given answers to any of the questions
during the educational session. At the conclusion of the
lecture, a postsession assessment examination was adminis-
tered, consisting of different questions and clinical scenarios
based off of the same underlying tested principles.
In total, there were 2 separate sessions provided to
2 different groups of orthopedics residents from nonaffili-
ated programs. Group 1 (n¼13) and Group 2 (n¼19)
had their respective documentation and coding teaching
sessions given about 1 week apart. The same protocol was
used for both sites and the same instructor was in charge of
each session. Descriptive statistics were applied to evaluate
the difference in total scores on the examination before and
after intervention via a paired t-test. The 2 sites were
compared to investigate the reproducibility of total score
improvements. Student t-test and spearman’s correlation
coefficient were used to calculate for potential associations
between increasing postgraduate year (PGY) training level
and affiliated baseline test scores, as well as increasing PGY-
level of training and self-rated confidence in documentation
and coding scores (1 ¼“novice”to 5 ¼“expert”). Statistical
significance was set at p o0.05 for all tests performed.
Data were analyzed using SPSS Statistical Software (IBM
Corporation 2012, Somers, NY).
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 indi-
vidual total scores on the 24-point examination when
comparing the baseline and postsession scores (p ¼0.020)
(Table 1). When separated out by PGY-levels, the results
also demonstrated statistical significance (p o0.010, for all
years PGY-1 through PGY-5). In addition, when comparing
between the 2 separate sites and orthopedic resident groups,
there was no statistically significant difference noted in score
improvement magnitudes (p ¼0.631) (Table 1).
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Higher self-rating scores for level of confidence in
documentation and coding correlated positively with
increasing PGY-level of training (p ¼0.001). However,
increasing PGY-level of training did not correlate with
increasing score totals on the baseline assessment examina-
tion (p ¼0.990) (Table 2). When analyzing correct
response rates for the various tested concepts on the
assessment examinations, significant improvements were
made with respect to all concepts tested (Fig.). Table 3 lists
all topics discussed in the sessions.
DISCUSSION
Our study adds to the existing body of literature demon-
strating resident training deficiencies in teaching documen-
tation 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 coding
specialist.
4
Baseline total scores by resident PGY-level of training
showed significant variation and no statistically significant
correlation was noted with respect to more senior residents
scoring higher on the examination. An interesting finding
from this study highlights that although senior residents
were more likely to give themselves a higher score on the
self-rated confidence scale for coding knowledge, this higher
score did not correlate with a higher point total on the
baseline examination. These findings have been demon-
strated previously when comparing junior and senior
resident level operative report documentation practices,
17
and when comparing knowledge of appropriate clinical
examination documentation principles for evaluation and
management services.
13
Furthermore, several surveys of
practicing orthopedic attendings have suggested that the
vast majority of trainees feel inadequately prepared to
document and code for the services they provide.
10
Although our study to some degree demonstrates that the
basic documentation and coding principles can be learned
and applied quickly, we are limited in that we are unable to
ascertain the long-term retention for this knowledge among
residents. Furthermore, we are unable to make any con-
clusions for real-world clinical applications at this time. A
realistic approach to combat these limitations would be to
TABLE 1. Intersite Comparison for Documentation and Coding Teaching Session
Group 1
*
Group 2
*
Intersite p Values
Total residents (N ¼32) 13 19
PGY-1 1 4
PGY-2 4 4
PGY-3 1 3
PGY-4 3 3
PGY-5 4 5
Total score, baseline examination
†
12.9 ⫾2.5 (53.8%) 12.4 ⫾2.3 (51.7%) 0.547
Total score, postexamination
†
20.5 ⫾3.0 (85.4%) 19.0 ⫾2.5 (79.2%) 0.065
Total point score improvements
†
7.5 ⫾3.8 6.6 ⫾3.0 0.631
p Value (baseline vs post-exam scores) 0.020 0.020
*Groups 1 and 2 represent the 2 different orthopedic residency programs with resident participation and examination scores.
†
Scores presented as mean ⫾standard deviation (percentage correct) for all residents in the group.
TABLE 2. Association of PGY-Level of Training With Self-Rated Confidence in Documentation and Coding Scores and PGY-Level of
Training With Baseline Assessment Scores
Likert Score Baseline Score
PGY-level
PGY-1 (n¼5) 1.0 ⫾0.0 12.0 ⫾2.7
PGY-2 (n¼8) 1.0 ⫾0.0 13.9 ⫾1.9
PGY-3 (n¼4) 2.0 ⫾1.2 10.8 ⫾1.5
PGY-4 (n¼6) 1.7 ⫾0.5 12.2 ⫾2.7
PGY-5 (n¼9) 2.0 ⫾0.9 13.0 ⫾2.4
PGY-level vs Likert score (p value)
*
0.535 (0.001) –
PGY-level vs baseline test score (p value)
†
–0.002 (0.990)
*Spearman's correlation coefficient and Student t-test with p values (in parentheses) are calculated to determine the relationship between PGY-level
and self-rated scores for confidence in documentation and coding (1 ¼“novice”and 5 ¼“expert”).
†
Spearman's correlation coefficient and Student t-test with p values (in parentheses) are calculated to determine the relationship between PGY-level
and baseline assessment scores.
Bold values indicate statistical significance at the alpha = 0.05 level.
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advocate for annual repetition of the lecture in addition to
supplementing this proposed program with active question-
ing and feedback from attendings while the resident rotates
through the various subspecialties. Finally, this educational
session was tested on orthopedic residents only, and thus
limits any conclusions to be made for other medical and
surgical training programs; albeit the design was geared to
facilitate incorporation into a surgical training curriculum.
The most reasonable implementation strategy for increas-
ing resident knowledge in documentation and coding
principles is one that is quick, effective, and uses minimal
resources. Residency programs across specialties may be
discouraged at the time, cost, and effort needed to imple-
ment a cumbersome addition to the curriculum. This is
especially true for surgical residency training programs.
Funding cuts to graduate medical education in addition to
reduced resident work hours and increasing requirements to
demonstrate achievement of the core competencies poses a
handful of important threats to any further proposals for
curriculum changes.
13,15
Given these competing obliga-
tions, the impetus for the current study was to evaluate
the effectiveness of a high-yield, 45-minute lecture to any
existing didactic schedule. Although this may very well
represent a “bare minimum”approach to a much broader
goal, it is a step in the right direction toward a more
comprehensive training program for all residents.
In keeping pace with today’s health care environment, the
proposed curriculum addition represents significant knowledge
acquisition for orthopedic residents in line with potential future
cost-containing strategies to increase the efficiency, value, and
care provided by tomorrow’s physicians. In February 2015,
Centers for Medicare and Medicaid Services released the
Medicare fee-for-service 2013 improper payments report, stating
the improper payment rate from July 2011 to June 2012 was
10.1%, translating to $34 billion in incorrect Medicare pay-
ments.
1
Furthermore, with 17% of the national gross domestic
product
20
currently being utilized by healthcare services and
expenses, and the projected increase to 30% by 2030, a modest
reduction in improper billing and coding practices of physicians
can serve as an important step in the right direction for cost
containment strategies.
Future directions of the study include specialty-specific
high-yield lectures that can be incorporated in a similar
fashion as we have shown here. In addition, analyzing the
real-world clinical application and resident assessment and
standardized feedback from attendings (or coding person-
nel) will be important moving forward. Indeed, with the
recent nationwide conversion from ICD-9 to ICD-10
warranting more specific documentation and coding prac-
tices to enhance the integrity of the electronic health record
to optimize patient care and long-term outcomes, this may
be the most advantageous window of opportunity to focus
more time and attention on improving resident knowledge
in accurate documentation, coding, and billing practices.
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 participat-
ing orthopedic residents encompassing all levels of training.
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Medicare fraud
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