Background: Proper clinical documentation is essential for effective medical service provision. Inaccurate documentation results in poor communication, ineffective patient care, and reduced compensation for the hospital. [1] A previous study analyzed documentation errors between 06/2021-07/2022 within the internal medicine residency inpatient service at an academic rural teaching hospital. [2] Their findings estimated a financial loss of $101,379.60-111,026. Consequently, Attending-led educational sessions were developed to improve the quality and consistency of documentation. This study investigated the effects of this intervention.
Methods: A retrospective analysis was conducted on inpatient charts (n=483), from 07/01/2022- 06/30/2023, under the internal medicine residency service at an academic rural teaching hospital. Instances of documentation inconsistencies (n=64) were identified and categorized by common procedural technology (CPT) codes. Subsequent value adjustments were determined in accordance with institutional guidelines. Economic impact estimation utilized the work relative value units (wRVU) correction factors for 2022 ($33.59) and 2023 ($33.06), yielding a range of projected losses. [3,4] Total calculated loss was estimated by assuming a 5% audit rate. Additionally, the 2022 and 2023 wRVU correction factors were applied to the results from the previous study [2] for a direct comparison of estimated financial impact.
Results: Analysis of documentation inconsistencies demonstrated the highest incidence of downgrading events from CPT 99223-99222 (17, 26.56%) followed by 99223-99221 (14, 21.88%), and 99239–99238, (5, 7.81%). Other notable down-coding events occurred at 99233–99232, (4, 6.25%), 99223–99233, (2, 3.13%) with a singular recorded incidence (1.56%) of downgrade from 99236–99235 and 99239–99232. Intriguingly, there were instances of CPT code upgrades, wherein the level of documentation permitted a higher billing level than initially proposed (n=20). The majority occurred with CPT 99232–99233, (11, 17.19%), with additional upgrades noted in 99238–99239, (4, 6.25%), 99231–99232, (4, 6.25%), and 99222–99223, (1, 1.56%). Overall, a wRVU loss of 37.02 was recorded. Application of the 2022-2023 wRVU correction factor estimates a financial impact of $1223.88-1243.52 within these patient encounters. Assuming a consistent dataset at a 5% audit rate, these findings suggest a loss of $24,477.60-$24,870.40. Applying the same wRVU correction factors to the previous study’s findings (120.69 wRVU lost), a loss of $79,800.20-81,079.54 is calculated. In comparison, there is a $54,929.8-56,601.94 difference in the estimated annual revenue lost.
Conclusions: These findings illustrate a discernible improvement in documentation accuracy among medical residents subsequent to an educational intervention. An estimated cost savings of $54,929.8-56,601.94 at this hospital is projected for the period spanning 07/01/2022 to 06/30/2023. Notably, this impact was achieved with the delivery of only four educational sessions. These results reinforce the benefit and importance of incorporating comprehensive training in accurate documentation early in the medical residency program.