Coding Improvement Project: Resident Education on Documentation

NCT04538196 | Withdrawn

• 1 other identifier: H-35600
• Study Type: interventional
• Target: N/A
• Locations: 1 country
• Sites: 1

Brief Summary

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.

Conditions

Resident Education

Outcome Measures

Primary Outcomes (2)

• Coding Analyst Quota

  the number of charts translated into ICD-9 and CPT codes per day

  up to 72 weeks

• Coding Analyst Satisfaction

  This will be assessed by administering the Maslach Burnout inventory validated survey

  up to 72 weeks

Secondary Outcomes (3)

• Relative Value Unit

  up to 72 weeks

• Diagnosis Related Groups

  up to 72 weeks

• Resident self-efficacy

  up to 36 weeks

Study Arms (2)

R Education

EXPERIMENTAL

Invervention: Resident who receives education on documentation and coding at the beginning of the surgical rotation

Other: Resident education on documentation and coding

R no Education

NO INTERVENTION

Resident who does not receive information on documentation and coding at the beginning of the surgical rotation

Interventions

Resident education on documentation and coding OTHER

Surgery residents will receive education on documentation and coding at the beginning of a particular surgical rotation vs the control group who will receive no education on documentation

R Education

Eligibility Criteria

• Age: 21 Years - 65 Years
• Sex: all
• Healthy Volunteers: Yes
• Age Groups: Adult (18-64), Older Adult (65+)

You may qualify if:

• 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 2016.
• 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.

You may not qualify if:

• 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.

Sponsors & Collaborators

• Baylor College of Medicine: lead

Study Sites (1)

Baylor College of Medicine

Houston, Texas, 77030, United States

Location

Related Publications (6)

• Yount KW, Reames BN, Kensinger CD, Boeck MA, Thompson PW, Forrester JD, Upchurch GR Jr, Gauger PG, Kron IL, Lau CL. Resident awareness of documentation requirements and reimbursement: a multi-institutional survey. Ann Thorac Surg. 2014 Mar;97(3):858-64; discussion 864. doi: 10.1016/j.athoracsur.2013.09.100. Epub 2013 Dec 4.

  PMID: 24315406 BACKGROUND

• Fakhry SM. Billing, coding, and documentation in the critical care environment. Surg Clin North Am. 2000 Jun;80(3):1067-83. doi: 10.1016/s0039-6109(05)70114-6.

  PMID: 10897279 BACKGROUND

• Fakhry SM, Robinson L, Hendershot K, Reines HD. Surgical residents' knowledge of documentation and coding for professional services: an opportunity for a focused educational offering. Am J Surg. 2007 Aug;194(2):263-7. doi: 10.1016/j.amjsurg.2006.11.031.

  PMID: 17618817 BACKGROUND

• Benke JR, Lin SY, Ishman SL. Directed educational training improves coding and billing skills for residents. Int J Pediatr Otorhinolaryngol. 2013 Mar;77(3):399-401. doi: 10.1016/j.ijporl.2012.11.039. Epub 2012 Dec 29.

  PMID: 23277302 BACKGROUND

• Russo R, Fitzgerald SP, Eveland JD, Fuchs BD, Redmon DP. Improving physician clinical documentation quality: evaluating two self-efficacy-based training programs. Health Care Manage Rev. 2013 Jan-Mar;38(1):29-39. doi: 10.1097/HMR.0b013e31824c4c61.

  PMID: 22472728 BACKGROUND

• Lusco VC, Martinez SA, Polk HC Jr. Program directors in surgery agree that residents should be formally trained in business and practice management. Am J Surg. 2005 Jan;189(1):11-3. doi: 10.1016/j.amjsurg.2004.05.002.

  PMID: 15701483 BACKGROUND

MeSH Terms

Interventions

Clinical Coding

Intervention Hierarchy (Ancestors)

Forms and Records Control; Office Management; Practice Management; Professional Practice; Organization and Administration; Health Services Administration; Medical Records; Records; Data Collection; Health Care Evaluation Mechanisms; Quality of Health Care; Health Care Quality, Access, and Evaluation; Epidemiologic Methods; Public Health; Environment and Public Health

Study Officials

• Panagiotis Kougias, MD

  Baylor College of Medicine

  PRINCIPAL INVESTIGATOR

Study Design

• Study Type: interventional
• Phase: not applicable
• Allocation: RANDOMIZED
• Masking: SINGLE
• Who Masked: PARTICIPANT
• Purpose: OTHER
• Intervention Model: PARALLEL
• Sponsor Type: OTHER
• Responsible Party: PRINCIPAL INVESTIGATOR
• PI Title: Vascular Surgery Chief

Study Record Dates

• First Submitted: March 16, 2020
• First Posted: September 4, 2020
• Study Start: April 14, 2015
• Primary Completion: September 1, 2020
• Study Completion: December 1, 2020
• Last Updated: September 4, 2020

Record last verified: 2020-08

Locations

US (1)