2019 HSC Section 2 - Practice Management

locating the correct code, but a more user-friendly interface may add to the utility of the system as a whole. There should also be recognition of the residents ’ role in good coding habits. A user-friendly search interface would still result in poor coding accuracy if inconsistent coding practices are used by residents. Inconsistency in coding within all settings (clinic, emer- gency department, and operating room) may lead to inaccuracy in procedural case logs. 1 Neurology residents have been shown to only log 50% of their procedures performed, and medical students in the emergency depart- ment during formal rotation only logged 60% of diagnoses treated. 6 , 8 These fi ndings do not address accuracy, merely the rate of reporting. Nygaard et al. 5 discussed other sources of bias including transcription errors and poor recall. They found that even with weekly prompting, 6.7% to 50.0% of potential cases were not logged by junior residents. In our questionnaire results, we found that the highest proportion of respondents (33%) log cases only once a month. The remaining respondents reported input frequency of “ daily, ” “ multiple times per week, ” and “ multiple times per month ” as the next most frequent responses (18.5% for all). As the number of procedures performed increases each PGY year, accurate recall may become more dif fi cult with larger intervals to recording cases. Previous studies have shown that senior residents have more accurate case logs than junior residents. 5 However, our analysis shows that only one of our residents reviewed showed signi fi cant improvement in accuracy over the course of their training. This, however, may be somewhat mis- leading as the total case numbers for all the residents ’ PGY1 and PGY2 years were signi fi cantly lower than their senior years. The vast majority of our residents responded that they believe they correctly code the procedure performed “ most of the time ” (74%), and the majority also report that they believe their case log would accurately represent their operative experience (66.6%). The discrepancy between perceived and actual accuracy has important implications for life after residency. ACGME case logs are used for hospital accreditation, societal memberships, and board certi fi cation. 9 Inaccuracy in the case log may compromise the integrity of a given certi fi cate or membership. Further- more, these accreditation and societal memberships imply competence. Competence in a given procedure does not necessarily come from experience in that procedure. 3 Despite meeting minimum criteria for operative experience, a resident ’ s competency is largely determined by the faculty ’ s overall assessment of the resident, and previous studies have suggested that the idea of competence in all aspects of surgery may be dif fi cult despite adequate case numbers. 3 Furthermore, the assessment of competence is dif fi cult as there are multiple aspects beyond technical skill that characterize a surgeon ’ s capability to practice. 10 How- ever, experience has been shown to correlate with comfort level in a given procedure. 4 Despite this, self-reported

their training. The questionnaire responses from our resi- dents indicated that one of the largest challenges to accurate coding was inability to fi nd the precise code using the ACGME search interface (85.19%). The second and third most frequent responses were “ unfamiliarity with available codes in the ACGME CPT directory ” and “ lack of formal education on procedural coding ” at 59.26% and 37.04%, respectively. The new regulations set forth by the American Board of Surgery regarding junior resident case minimums make accurate and consistent coding of utmost importance going forward. Addressing the concerns voiced by current residents regarding their perceived barriers to accuracy may improve resident coding accuracy. Communication between resident and attending preop- eratively and postoperatively regarding the CPT code for the case performed as well as formal resident education in coding may improve accuracy of ACGME case logs; however, many attendings may not know the exact CPT code depending on how coding is done at their institution. Previous studies have investigated accuracy in CPT and evaluation and management coding among family medi- cine residents before and after formal coding education and found that despite an increase in accuracy over time, formal instruction may not be the cause for improvement. 6 Residents at our institution do not receive formal educa- tion regarding CPT coding, and results from our ques- tionnaire show that they feel this would help their accuracy for procedural coding. However, fi nding appropriate time and determining the ideal format for formal education of residents may be challenging given the many other educa- tional requirements that occur during residency. Proce- dural coding was not developed to serve the practicing physician, so its nuances are often not intuitive. Further- more, communication between attending surgeon and resident surgeon presupposes that the attending surgeon themselves are comfortable and accurate with the CPT coding catalog. Nonetheless, we propose that the most direct and meaningful way to improve accuracy is by simple communication between attending surgeon and resident surgeon on the terms to use, and focus less on the actual code. One opportunity for improvement inherent to the case log system that is cited by our respondents as a major obstacle to accurate coding is the ACGME case log search engine. Improving the ACGME case log interface search engine could result in improved accuracy. Currently, search engine terms must be met exactly for matches to appear. Thus, fi nding the precise procedure performed can be a challenge. The fi ndings of Lee et al. 7 showed similar barriers regarding user interface when coding emergency department patients ’ diagnoses. Furthermore, as the ACGME case log system does not track all codes, certain nonspeci fi ed procedures may not be found at all within its search terms. The interface does, however, allow residents to choose codes from de fi ned categories of procedures. These do help in

Journal of Surgical Education Volume 73/Number 6 November/December 2016

4