Surgical residents’ knowledge of documentation and coding for professional services: an opportunity for a focused educational offering

• Published in: The American journal of surgery 2007-08, Vol.194 (2), p.263-267
• Main Authors: Fakhry, Samir M., M.D., F.A.C.S, Robinson, Linda, M.S., M.A., R.N, Hendershot, Kimberly, M.D, Reines, H. David, M.D., F.A.C.S
• Format: Article
• Language: English
• Subjects: Adult; Aged; Attitude of Health Personnel; Codes; Core competencies; Documentation; Female; Forms and Records Control; Hospitals; Humans; Insurance Claim Reporting; Internship and Residency; Male; Medical records; Medical Staff, Hospital - psychology; Medicare; Meetings; Middle Aged; Mortality; Needs Assessment; Physicians; Postoperative period; Professional Competence; Specialties, Surgical - education; Surgery
• ISSN: 0002-9610; 1879-1883
• DOI: 10.1016/j.amjsurg.2006.11.031

Abstract Introduction A working knowledge of documentation and coding for physician services (DCPS) is increasingly important for a successful practice. There is no standardized, widely available educational offering available to surgical residents in DCPS. The purpose of this study was to survey surgical residents and attendings for their knowledge of documentation and coding and their opinions about its importance in their training and practice. Methods A convenience sample of 60 surgical residents and 46 attendings from 5 surgical residency training programs were administered a written survey on DCPS. Results The majority of residents were male (60%), in university-based programs (82%), and planned to work in a surgical specialty (55%) A larger proportion of attendings were male (80%) and in general surgery practice (62%), and a smaller proportion was university based (61%). Similar proportions of residents and attendings, 82% and 89%, respectively, stated they had not received adequate training in DCPS. The vast majority of residents (85%) felt they were novices at coding and billing, whereas 61% of attendings stated that they were somewhat knowledgeable. As a group, residents answered 54% of 25 knowledge questions correctly, and attendings answered 77% correctly. Ninety-two percent of residents believed that expertise in DCPS would make a difference in their practice, whereas 80% of attendings stated that this knowledge was currently important to their practice. Similar proportions of residents and attendings, 85% and 87%, respectively, thought that it should be an important part of residency training. Conclusions Residents in this survey are aware of the importance of DCPS but feel inadequately prepared for this area of practice. The residents’ knowledge of basic concepts in DCPS is marginal. Attendings surveyed had similar opinions and somewhat better knowledge of the subject. A widely available, standardized educational offering on DCPS is needed and should be provided as part of the practice-based core competencies of surgical residency training.