Coding and Documentation Education for General Surgery Residents
试验速览
- 阶段
- 不适用
- 状态
- 撤回
- 试验地点
- 1
- 主要终点
- Coding Analyst Quota
研究概览
简要总结
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.
详细描述
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.
研究设计
- 研究类型
- Interventional
- 分配方式
- Randomized
- 干预模型
- Parallel
- 主要目的
- Other
- 盲法
- Single (Participant)
入排标准
- 年龄范围
- 21 Years 至 65 Years（Adult, Older Adult）
- 性别
- All
- 接受健康志愿者
- 是
入选标准
- •All Surgery residents in the Baylor College of Medicine residency program rotating through a surgical rotation at the Michael E. DeBakey VA Medical Center between the months of November 2014 and November
- •Coding analysts employed in the Surgical Coding department at the Michael E. DeBakey VA Medical Center between the months of November 2014 and November 2016.
排除标准
- •Residents and coding analysts that do not wish to participate on the study,
- •Residents rotating through the a particular surigcal rotation more than once after being part of the intervention arm.
研究组 & 干预措施
R Education
Invervention: Resident who receives education on documentation and coding at the beginning of the surgical rotation
干预措施: Resident education on documentation and coding (Other)
R no Education
Resident who does not receive information on documentation and coding at the beginning of the surgical rotation
结局指标
主要结局
Coding Analyst Quota
时间窗: up to 72 weeks
the number of charts translated into ICD-9 and CPT codes per day
Coding Analyst Satisfaction
时间窗: up to 72 weeks
This will be assessed by administering the Maslach Burnout inventory validated survey
次要结局
- Relative Value Unit(up to 72 weeks)
- Diagnosis Related Groups(up to 72 weeks)
- Resident self-efficacy(up to 36 weeks)
研究者
Panos Kougias
Vascular Surgery Chief
Baylor College of Medicine