Background: The importance of accurate patient documentation for effective medical communication and financial compensation is well-documented. However, appropriate medical billing based on medical documentation is not emphasized in graduate medical education. We performed a review and analysis of resident charting errors during inpatient rotations to improve documentation and billing skills.

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 adult patients admitted to general medicine and intensive care teaching services from July 2021 to June 2022. Regular monthly billing audits by clinical coders were conducted on 5% of randomly selected patient encounters. CPT codes 99223, 99222, and 99221 represent H&P encounter level 3, 2, and 1, respectively. CPT codes 99233, 99232, and 99231 represent follow-up encounter level 3, 2, and 1, respectively. CPT codes 99239 and 99238 represent discharge level 2 and 1, respectively. The level of service is determined by four components – history, physical examination, medical decision-making, and total time. History can be further divided into the chief complaint, elements of history of present illness, review of systems, and past family/social histories. The encounters were downgraded to lower CPT codes, based on CMS billing guidelines if any deficiency in the documentation was identified.

Results: 511 of 10231 total charges were audited. 82 charges were deficient, representing a 16% error rate. Of the charts downgraded due to insufficient documentation – missing review of systems – 43 (52%); discharge management time – 20 (24%); past family history -14 (17%); social history – 6 (7%); incorrect medical decision making – 6 (7%); insufficient history of present illness – 5 (6%); chief complaint – 5 (6%); insufficient physical exam – 4 (5%); past medical history – 2 (2%), and past surgical history 1 (1%). A structured peer education curriculum was prepared by residents in conjunction with attending physician staff. A clinical coding sheet with documentation guidelines was disseminated alongside live education during scheduled conferences. Real-time resident feedback was implemented during inpatient rotations to decrease errors. Simultaneously, attending attestation discharge templates were updated to include discharge management time.

Conclusions: The CMS states, “it is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.” Routine review of CPT coding errors provides an opportunity to improve residents’ awareness of billing requirements, strengthen medical documentation, and engage in ongoing peer education.