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Teaching residents coding and documentation: effectiveness of a problem-oriented approach.

Sawsan As-Sanie·Denniz Zolnoun·Mary Ellen Wechter·Georgine Lamvu·Frank Tu·John Steege
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Abstract

OBJECTIVE: We sought to assess the effectiveness of a problem-oriented approach to teaching residents accurate coding and documentation of ambulatory gynecology visits. STUDY DESIGN: This was a pilot before-and-after study. Nine resident volunteers underwent 4 individual instructional sessions on coding and documentation with a trained faculty member over 6 weeks. Outcomes were assessed by comparing the appropriateness of procedure and diagnostic codes billed in participant continuity clinic prior to and in the 6 to 9 months following the intervention. RESULTS: Following the intervention, participants demonstrated an increase in the accuracy of coding the correct category of the evaluation and management service, an increase in the appropriate use of modifiers, and a decline in undercoding errors. CONCLUSION: Problem-oriented interactive learning appears to be an effective method of teaching residents proper coding and documentation.

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Feasibility StudiesGynecologyHealthcare Common Procedure Coding SystemInternship and ResidencyMedical Records, Problem-OrientedObstetricsPilot ProjectsJournal Article

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Sawsan As-Sanie, Denniz Zolnoun, Mary Ellen Wechter, Georgine Lamvu, Frank Tu, John Steege. 2005. Teaching residents coding and documentation: effectiveness of a problem-oriented approach.. https://doi.org/10.1016/j.ajog.2005.08.004

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