R. Howard1, R. Reddy1 1University Of Michigan,Ann Arbor, MI, USA
Introduction:
Accurate medical documentation is a core competency in medical education and is critical to successful surgical practice. As such, significant time is dedicated to teaching documentation skills to medical students, including writing a history, physical examination, and plan. However, students receive little to no education regarding documentation compliance with evaluation and management (E/M) coding that is applied to all patient encounters in the United States. The following study aims to assess the coding compliance of medical student documentation.
Methods:
One hundred medical records at a thoracic surgery clinic in an academic medical center were retrospectively audited that contained documentation by both the attending surgeon and a third year medical student for the same patient encounter. Faculty documentation was composed by one faculty member, and student documentation by 47 students. Records were then de-identified and assigned a level of service by trained, expert coders using a Current Procedural Terminology (CPT) E/M code. Differences in CPT code were then compared between medical student and faculty documentation.
Results:
Of the 100 clinical encounters, 80 were new patient evaluations and 20 were postoperative visits. Medical student documentation was coded at the same level of service in 38 cases, a lower level of service in 53 cases, a higher level of service in one case, and an incorrect service in 8 cases (postoperative visits coded as new evaluations). Among new patient evaluations, student documentation was more likely to be coded at a lower level of service. For example, 93% of faculty documentation was coded as a Level 4 encounter compared to only 29% of student documentation. Reasons for lower CPT code were lack of detail in history of present illness (HPI) and insufficient number of systems in physical examination.
Conclusion:
When compared to faculty documentation, medical student documentation is coded at a lower level of service due to lack of detail in HPI and physical examination. Although students receive extensive teaching regarding documentation, these results reflect the need for education regarding E/M coding, which is integral to real world practice. Therefore, additional teaching on this topic is merited in medical education.
