Resident Education Clinical Trial
Official title:
Coding and Documentation Education for General Surgery Residents
Most General Surgery program directors have expressed the necessity to educate residents on the business aspect of medicine. However, the literature review did not produce any interventional studies directly addressing coding and documentation in General Surgery Residents. The purpose of this study is to address specific coding and documentation mistakes as identified by surgery coding analysts in the surgical department. Through this examination, we hope to provide residents with the necessary tools and framework for adequate documentation throughout their surgical careers.
Background:
Research has shown that residents have limited knowledge on documentation requirements.
However, correct coding and documentation plays a pivotal role in today's health care system.
Inadequate billing and coding in health record documentation can constitute fraud and abuse.
Surgeons that are trained on proper billing and coding can be instrumental to reducing waste
and increasing efficiency throughout the sphere of health care. The low quality of physician
documentation has been widely recognized; however, definitive measures correcting the
situation are absent. Truthfully, most residents are unaware that ICD-9 data is used for
planning, reimbursement, quality rating, Medicare Conditions of Participation, JCAHO Core
Measures thereby reinforcing the lack of understanding regarding the importance of such
codes.Lack of education and time constraints results in poor physician documentation and as a
consequence, inadequate coding leads to delayed or denied reimbursements. Several studies
have shown under-billing and down-coding from resident encounters. However, no interventional
studies directly addressing coding and documentation in General Surgery Residents were
identified.
Purpose and objectives:
Objective 1: To educate general surgery residents on proper documentation; therefore,
facilitating coding analyst efficiency by increasing processing time and employee
satisfaction.
Hypothesis 1: Increasing note clarity will improve coding analyst productivity and output.
Objective 2: To ensure fair and accurate re-imbursement by appropriate translation of
documentation to ICD-9 and CPT codes.
Hypothesis 2: Better reimbursement accuracy will result from an increase in precise, clear
and complete medical records.
Objective 3: To increase self-efficacy in surgical trainees. Hypothesis 3: By incorporating
appropriate documentation and coding techniques early on in their careers, we will observe
increase in documentation confidence among residents.
Design and Procedure:
To initiate this study, surgical coding analysts at the Michael E. DeBakey Department of
Veteran Affairs (MEDVAMC) will be interviewed on the most commonly encountered documenting
mistakes in current practice at the surgery department. We intend to conduct a blinded
randomized, control trial examining documentation entered by surgical trainees who receive no
documentation education compared to trainee documentation after education. Endpoints will be
measured by evaluating coding analyst quota which is defined as the number of charts
translated into ICD-9 and CPT codes per day. Additionally, we will also be evaluating
employee satisfaction as defined by the Maslach Burnout inventory; a well-researched
validated survey. A time range of twelve months, starting from day one of a surgical
rotation, will be used in each arm of the study. Trainees with no education on documentation
will serve as the control group while those who recieve documentation education will make up
the intervention group. Outcomes will be measured by changes in quota, and coder satisfaction
as described above. Randomization: A randomized block design will be employed with each
surgery rotation month as a unit of randomization. In other words, surgery trainees will be
randomly assigned to the control or intervention group per rotating month. Since residents
rotate through a surgical service every 30 days, randomization will be done per month.
Blinding and allocation concealment:
The random month assignment will take place in advance using a pre-sealed envelope containing
the randomization arm that will be opened the day prior to the start of the next surgical
trainee rotation. The coders and surgical trainees will be blinded to the group allocation.
Furthermore, surgery residents rotating through a surgical rotation at the VA during an
intervention month will be trained on documentation and coding on the first day of their
rotation; the teaching session will be about 20 minutes with high yield information on proper
documentation and coding. The content of the teaching session will be determined through
interviews conducted with the coding analysts. In addition to this session, a note card will
be provided to the residents stressing the importance of proper documentation as well as
serving as a reference tool.
At the end of the rotation, an anonymous survey will be provided to the residents in order to
assess if their documentation skills changed after the intervention. In addition, the coding
analyst will also complete the Maslach Burnout inventory survey, a well-researched validated
survey, to assess their employee's satisfaction in control vs intervention months. In
addition, de-identified generally available data on the surgery department, such as relative
value units and daily analyst quota will be collected. No identifiable provider information
will be collected.
Data Collection and Analysis Coding Analyst satisfaction will be analyzed with the Maslach
Burnout Inventory (MBI) provided at the end of each month. In addition, residents will be
surveyed on knowledge on coding and documentation confidence pre and post intervention.
Billing and documentation data from the surgical deparment will be collected. Data will be
analyzed using the t-test to determine if increasing the clarity of notes increases
productivity. Secondary outcomes: Coding analyst satisfaction scores and resident surveys
will be analyzed among the intervention and control groups using t-test.The criteria used for
statistical significance will correspond to a P= 0.05 and a confidence interval (CI) of 95%.
Analysis will be performed with STATA IC 13.0 (Stata Corporation, College Station, TX)
;
Status | Clinical Trial | Phase | |
---|---|---|---|
Recruiting |
NCT05887570 -
Procedure-Specific Resident Objective Modular Training Evaluation
|
N/A |