Background: The importance of accurate patient care records for effective communication and medical education is well documented. However, medical documentation as a tool for financial compensation is not emphasized in graduate medical education. We performed a review and analysis of resident charting errors during inpatient rotations to determine the potential revenue loss and economic impact.
Methods: A retrospective study was conducted at a single 158 bed rural hospital in Indiana with a newly accredited academic internal medicine residency program established in July 2020. We identified patients admitted to the hospital from July 2021 to June 2022. Inclusion criteria included patients ≥ 18 years old on teaching services (ICU and general medical floor). Regular monthly billing audits by clinical coders were conducted on 5% of randomly selected patient encounters. CPT code 99223, 99222 and 99221 represent H&P encounter Level 3, 2 and 1 respectively. CPT code 99233, 99232 and 99231 represent follow up encounter Level 3, 2 and 1 respectively. CPT code 99239 and 99238 represent discharge time >30 minutes and time < 30 minutes respectively. The encounters were downgraded to lower CPT codes (based on CMS guidelines of billing) if any deficiency in documentation was identified. Total revenue loss was estimated based on the number of wRVUs lost due to each CPT code downgrade. We used $42 and $46 as base value for each wRVU at our institution and national average respectively.
Results: 511 of 10231 total charges were audited. 82 charges were found to be deficient, representing a 16% error rate. Some of the errors that resulted in billing downgrades were insufficient documentation of review of systems; past medical, social or family history; medications, physical exam and missing chief complaint. We noted incidents of downgrades 99223 to 99221 – 51 (62%); 99239 to 99238 – 20 (24%); 99223 to 99222- 4 (4.9%), 99233 to 99232 – 4 (4.9%) and 99222 to 99221- 2 (2.4%). The revenue loss within the sample due to CPT code downgrade was $5,043.36 – $5,523.68. The total revenue lost across all encounters was estimated at $101,379.60 – $111,026.80.Intervention: Resident education teaching aides and ongoing process monitoring were implemented to improve accurate documentation practices.
Conclusions: This study demonstrates the potential revenue loss due to inadequate medical documentation. Basic medical billing and coding education in graduate medical education may reduce billing errors, improve clinical documentation, and have a positive economic impact on local healthcare systems.Intervention: Intervention: Resident education teaching aides and ongoing process monitoring were implemented to improve accurate documentation practices.