RT Journal Article
SR Electronic
T1 The Impact of a Documentation and Coding Curriculum in an Obstetrics and Gynecology Continuity Clinic
JF Ochsner Journal
JO Ochsner J
FD O. P. Jindal Global University
SP 354
OP 358
VO 12
IS 4
A1 Gala, Rajiv B.
A1 Chiang, Seine
YR 2012
UL http://www.ochsnerjournal.org/content/12/4/354.abstract
AB 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.