- Email: [email protected]
Practice management education during surgical residency
The American Journal of Surgery (2008) 196, 878 – 882
The Southwestern Surgical Congress
Practice management education during surgical residency Kory Jones, M.D., Ricardo A. Lebron, M.D., Alicia Mangram, M.D.*, Ernest Dunn, M.D. Department of Surgery, Methodist Health System, 221 W. Colorado, Pavilion 1, Suite 100, Dallas, TX 75208, USA KEYWORDS: Practice management; Resident education; Coding
Abstract BACKGROUND: Surgical education has undergone radical changes in the past decade. The introductions of laparoscopic surgery and endovascular techniques have required program directors to alter surgical training. The 6 competencies are now in place. One issue that still needs to be addressed is the business aspect of surgical practice. Often residents complete their training with minimal or no knowledge on coding of charges or basic aspects on how to set up a practice. We present our program, which has been in place over the past 2 years and is designed to teach the residents practice management. METHODS: The program begins with a series of 10 lectures given monthly beginning in August. Topics include an introduction to types of practices available, negotiating a contract, managed care, and marketing the practice. Both medical and surgical residents attend these conferences. In addition, the surgical residents meet monthly with the business office to discuss billing and coding issues. These are didactic sessions combined with in-house chart reviews of surgical coding. The third phase of the practice management plan has the coding team along with the program director attend the outpatient clinic to review in real time the evaluation and management coding of clinic visits. RESULTS: Resident evaluations were completed for each of the practice management lectures. The responses were recorded on a Likert scale. The scores ranged from 4.1 to 4.8 (average, 4.3). Highest scores were given to lectures concerning negotiating employee agreements, recruiting contracts, malpractice insurance, and risk management. The medical education department has tracked resident coding compliance over the past 2 years. Surgical coding compliance increased from 36% to 88% over a 12-month period. The program director who participated in the educational process increased his accuracy from 50% to 90% over the same time period. CONCLUSIONS: When residents finish their surgical training they need to be ready to enter the world of business. These needs will be present whether pursuing a career in academic medicine or the private sector. A program that focuses on the business aspect of surgery enables the residents to better navigate the future while helping to fulfill the systems-based practice competency. © 2008 Elsevier Inc. All rights reserved.
Surgical education has undergone radical changes in the past decade. For example, the introduction of laparoscopic surgery has required the implementation of a skills laboratory. Endovascular techniques have changed * Corresponding author: Tel.: ⫹1-214-947-2303. E-mail address: [email protected] Manuscript received May 6, 2008; revised manuscript August 13, 2008
0002-9610/$ - see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2008.08.008
how the residents are taught in the operating room. The use of the 6 competencies is an integral part of surgical training. An area that has met very little change is the education of the surgical residents in the business aspects of medicine. Few programs have a formalized program to teach the surgical residents proper coding and documentation. In a recent survey Fakhry et al1 stated that 85% of residents believed
K. Jones et al.
Practice management education
they were a novice at coding and billing. This is a significant issue for a resident setting up an office practice because reimbursement continues to decrease while office overhead increases. The young academic surgeon is not immune to this problem because surgical chairmen are now looking very closely at the billings of the young faculty members. Another problem to be met is the increasing scrutiny of documentation and subsequent coding for services linked to Medicare and Medicaid. In the recent past the Centers for Medicare and Medicaid Services have begun to audit academic institutions and teaching programs. Failure to adequately document services has the potential to result in huge penalties and repayments. The purpose of this article is to present our program, which has been in place over the past 2 years and is designed to teach the residents practice management. In addition, this program enables the residents to participate in the systems-based core competency.
100.0% 90.0% 90.0% 80.0%
88.0%
80.0% 70.0% 60.0% 61.0%
60.0% 50.0% 50.0%
47.7%
40.0%
36.2%
30.0% Residents
20.0%
Program Director 10.0% 0.0% 1
2
3
4
Figure 1 Quarterly evaluation of coding accuracy of the surgical residents and program director. ⽧, Residents; , program director.
Methods The Methodist Medical Center of Dallas has a graduate medical education program that incorporates 4 core programs: general surgery, internal medicine, obstetrics and gynecology, and family practice. The surgical practice management program is composed of 3 parts. The first part is a series of monthly lectures given by the hospital administrative staff. The residents of all the programs are invited to a 1-hour lecture given at noon. The lectures include topics such as an introduction to types of practices available, negotiating a contract, managed care, and marketing a practice. Resident evaluations were completed for each of the practice management lectures. The responses were recorded on a Likert scale,1–5 in which the lowest score corresponds to “information is not pertinent” and the highest score corresponds to “information very pertinent” (Table 1).
Table 1
879
Practice management lecture series
Practice management lecture series
Likert score
Documentation and Coding Guidelines Types of practices—advantages and disadvantages Finding a job Evaluating employment agreements and recruitment agreements Understanding malpractice insurance and risk management Billing, billing compliance, and accounts receivables management Managed care 101: understanding the basics Accounting 101: developing a practice performance and business plan Marketing your practice Investing and financial planning
4.1 4.4 4.3 4.8 4.8 4.2 4.0 4.2 4.1 4.4
The second part of the program consists of a series of morning 1-hour meetings with the surgery residents, dealing specifically with documentation and coding (Fig. 1). Both inpatient and outpatient coding is discussed. This format consisted of both didactic lectures combined with actual chart reviews. The institutional coding and compliance manager has an open dialogue with the residents to explain how and when certain codes and modifiers are to be used. The third part of the program involves active participation in the clinic setting with the residents and coding personnel. At the end of a patient encounter the program director and surgical resident present the chart to the coding and compliance manager who will agree or disagree on the level of service coded. The role of appropriate Evaluation and Management (E/M) service codes and modifiers are discussed. The second and third parts of this education program were evaluated through chart audits performed on a quarterly basis. The audit consists of 10 evaluation and management service codes per provider per quarter. The 10-chart sample is determined by a computerized random selection process from each provider’s total patient population during the specific quarter. The coding and compliance manager performs all audits and reports to the compliance committee. The compliance committee has set an 80% overall accuracy standard that all providers must meet. The 80% overall coding accuracy includes both undercoded claims and overcoded claims. The surgical residents were evaluated individually and as a group. The surgical program director was evaluated on an individual basis.
Results Resident evaluations were completed for each of the practice management lectures. The responses were recorded
880
The American Journal of Surgery, Vol 196, No 6, December 2008
on a Likert scale1–5 (Table 1). The scores ranged from 4.1 to 4.8 (average, 4.3). The highest scores were given to lectures discussing negotiation of employee agreements, recruiting contracts, malpractice insurance, and risk management. Chart audits were performed quarterly over a 1-year period. Surgical coding compliance for the residents increased from 36% to 88% over the 12 months. The surgical program director, who participated in the same education process, increased his accuracy from 50% to 90% over the same time period (Fig. 1). Some errors still persisted. Inpatient coding problems occurred in the nonsurgical patients who were managed medically. Only lower-level codes can be used daily on patients who are stable or making progress. The surgery residents tended to use higher-level codes based on possible case complexity. In the outpatient clinic coding errors were seen as a result of failure to document an adequate number of bullet points in the review of systems. This resulted in significant underbilling of provided services. The improvement in the surgical program director’s compliance was related to better documentation in both the inpatient and outpatient setting. Although the patients had been seen and progress notes by the residents were signed by the program director, the specific wording, “I have seen and examined the patient,” was not always included. Surgical notes defining staff participation were always in compliance and did not change during the survey period.
Comments For graduating surgical residents there is increased complexity and uncertainty when entering the business of medicine. Residents need to be aware of the ever-changing legal, organizational, managerial, and reimbursement issues. The practice management program at Methodist Hospital of Dallas has tried to address some of these concerns. The program aims at issues such as employment contracts, office operations and management, financial and personal management, regulatory issues, insurance processing, coding, and billing, among other important issues. Interestingly, although we have adapted the surgical curriculum to meet innovations in care such as laparoscopic surgery and endoscopic techniques, there has been little improvement in our education of the business aspects of medicine. Breitwieser et al2 in 1981 did a survey of 717 third-year family practice residents. Eighty-seven percent had no medical school lectures or seminars in the business of medicine. More than 66% of residents believed that they were unprepared in various office management topics.2 Ten years later, in 1991, Ridky and Bennett3 showed through a mailed survey of 8 academic surgery programs that 70% of past residents did not believe that they were well prepared in practice management issues. At the same time, a telephone survey of 117 academic medical centers showed that only
4% of surgery programs offered a formal course in practice management to their residents. The conclusion was that many graduating residents are spending valuable time at the beginning of their practice learning the basics of practice management.3 Unbeknownst to us at the time of implementation of our program, the suggested topics that Ridky and Bennett3 thought should be taught are indeed part of our management program. The problem has not gotten better over the past decade. Fakhry et al1 surveyed 5 surgical residency programs in 2007 and found that 85% of residents believed that they were inadequate at coding and billing. However, 92% of these residents believed that this was important to their practice. In addition, 80% of the attendings at these 5 institutions believed that this knowledge was valuable to their practice. These data are similar to the attitude reflected by our surgical residents. The attendance at monthly practice meetings has been high and the approval of the lectures has been very good (average Likert score, 4.3). Knowledge of E/M coding has a number of specific benefits. Physicians in both the private sector and academic divisions of general surgery are facing constant financial pressures. Kuo et al4 in 2003 looked at his own university general surgical division. They showed that substantial increased revenue could be generated from proper E/M coding and billing. Their conclusion was that E/M coding and billing were significantly underused in this patient population. This was similar to a prior study in 2001 by Ng and Lawless.5 They looked at the billing and coding practices of pediatric residents in outpatient clinics. The resident accuracy was 38% for acute care visits. Most errors were in undercoding for provided services. The loss of potential revenue was substantial. They believed that a residentstaffed clinic under these conditions would not be financially self-sufficient. We had the same problems in our outpatient clinic. Our initial resident coding accuracy was 36%, which is very similar to the 38% accuracy Ng and Lawless5 reported. Over a 12month period this improved to 88%. This improvement was only seen after a series of lectures (Fig. 1) and onsite chart review by the coding and compliance manager. The surgical program director saw an improvement in coding compliance from 50% to 90% over the same 12month period. The improvement was the result of better documentation of resident supervision. This is not an isolated problem to our institution. Howell et al6 in 1999 performed a survey of all emergency medicine (EM) residents taking the in-training examination. They had an 88% response rate. The EM residents recorded faculty supervision rarely. Twenty-five percent of residents “never” recorded faculty participation, whereas another 25% of EM residents recorded faculty involvement from 1% to 25% of the time.6 Centers for Medicare and Medicaid Services guidelines require evidence of faculty supervision. In the Howell et al6 study only 17% of EM residents documented faculty presence for procedures routinely. This has major
K. Jones et al.
Practice management education
implications for Medicare and Medicaid reimbursements. Federal audits have resulted in denied charges for a number of academic institutions. There are other reasons to provide accurate coding. An editorial by Mabry7 in 2007 stated that more accurate coding of procedures, comorbidities, and complications will provide better administrative data sets. This will enable more accurate measurements of patient risks and predict outcome. This may in turn potentially generate better diagnosis-related groups for hospital reimbursement.7 The American Board of Medical Specialties and the Accreditation Council for Graduate Medical Education and the Association of American Medical Colleges have now endorsed 6 primary competencies for graduate medical education. Systems-based practice is 1 of these 6 competencies. There are a number of components included in the systems-based practice such as understanding the health care organization, having knowledge of types of medical practices and delivery systems, and how to partner with health care managers and health care providers. The practice management program we have in place helps to satisfy this competency. The tracking of compliance improvement enabled us to grade success of the coding portion on the program. Personal communication with our graduating residents over the past 2 years has shown great satisfaction with the concept. They believe that the combination of the lecture series with practical every day billing and coding discussions has enabled them to make an easier transition into private practice. They also believed that the lecture series was helpful when creating a curriculum vitae and negotiating contract agreements. These lectures served as a guide to the resident beginning his practice.
Conclusions The graduating surgical resident today faces a multitude of business decisions when entering practice in either the private setting or academic medicine. Regardless of the type of surgical practice, financial issues will be permanent. Our program was established to help ease this transition. The American College of Surgeons has been an active participant and now provides a number of educational tools to help with coding and practice management. There is a need for surgical programs to address this issue early in the residency. This will allow the resident to assimilate this information over the length of his training rather than trying to learn these business skills during their first months in practice.
References 1. Fakhry SM, Robinson L, Hendershot K, et al. Surgical residents’ knowledge of documentation and coding for professional services: an opportunity for a focused educational offering. Am J Surg 2007;194:263–7. 2. Breitwieser D, Adye W, Arvidson M. Resident evaluation of current practice management training. J Fam Pract 1981;13:1063– 4.
881 3. Ridky J, Bennett T. Training surgery residents in group practice management. Med Group Manage J 1991;38:38 –9. 4. Kuo PC, Douglas AR, Oleski D, et al. Determining benchmarks for evaluation and management coding in an academic division of general surgery. J Am Coll Surg 2004;199:124 –30. 5. Ng M, Lawless ST. What if pediatric residents could bill for their outpatient services? Pediatrics 2001;108:827–34. 6. Howell J, Chisholm C, Clark A, et al. Emergency medicine resident documentation: results of the 1999 American board of emergency medicine in-training examination survey. Acad Emerg Med 2000;7:1135– 8. 7. Mabry CD. Surgical residents’ knowledge of documentation and coding for professional services: an opportunity for a focused educational offering. Am J Surg 2007;194:268 –9.
Discussion Dr. Jon Thompson (Omaha, NE): Dr. Jones and her colleagues are to be congratulated. They report that the practice management course was well received; however, the number of residents who actually participated in such training is not clear. Do you get a high attendance rate from the residents? Is it the time of day or of the format that would help you to be more successful? As you point out, what are the issues with billing and coding? Is it the timing of the documentation? You also mentioned a problem with not enough bullet points for review of systems or physical examination. Do you have an electronic medical record in your clinic setting? Have you done resident surveys or any other evaluations in these activities to better asses the educational impact? It certainly has been my impression, particularly with billing and coding, it takes a number of repeated lectures on the same topic until you start to get a satisfactory compliance. Finally, you conclude that this training is important early in residency. I would certainly agree with that in terms of the billing and coding documentation; however, my impression is that many of the practice management aspects become more relevant the closer you get to completing your training and thus should be more important at that time. Dr. Kory Jones (Dallas, TX): The first question—we actually had very good attendance. First of all, with the monthly lectures, it was given at lunch and all the residents were invited to attend. Any time you give free lunch to residents, I think you get a good turnout. We found a great deal of resident interest, especially in the upper-level residents. Of course, residents towards the end of their residency would come to these lectures more often. These were mandatory conferences, which we integrated into our mandatory basic science conferences. If we continue to do this all 5 years, which is what we intend to do, they have multiple opportunities to go to these lectures, which serves to reinforce the material. The coding personnel are always available and we see by the chart audits what we need to be concentrating on and so they will make themselves available to us at a later time in order to concentrate on those aspects. In the clinic, we do not have electronic records, but we have re-evaluated the forms that we use for documenting
882
The American Journal of Surgery, Vol 196, No 6, December 2008
our patient encounters, which serves as a reminder for the residents. We have not formally evaluated this from the resident; however, I can just say personally it has helped me tremendously when I started my practice. My partners were pleasantly pleased they did not have to spend a lot of time trying to take me through some of the coding issues when I started and I was able to more easily start my practice and begin billing immediately rather than learning these things on the job. Dr. Steve Smith (Wichita, KS): Have you continued to follow the performance of the residents in regards to compliance in the past 12-month period? Has the rather dramatic improvement that you saw have been maintained throughout the longer period? You also mentioned a little bit about recurrent training. How often do you think that is going to be necessary to maintain the high levels of compliance that you presently have? And, final question, has the increase in compliance actually translated into a better financial performance for the department? Dr. Kory Jones (Dallas, TX): We have continued to perform the chart audits. This is ongoing within our program and we have continued to have better compliance numbers throughout the time period that we have been doing this. After that dramatic increase we have continued to be in the upper 80th percentile. Of course, preliminary interns may have a lower compliance rate because they are not paying much attention and they are not as involved in the process. But, their compliance has also improved.
Dr. Ernest Dunn (Dallas, TX): Kory, can I just answer the second part? She is now gone into private practice. But the numbers are still holding at about 90% in terms of compliance. In terms of increased revenue, it is hard to say because in Texas, our clinic runs about 30% self-pay so I think we are doing a better job, but realistically how much of that will transfer into increased income is up for debate. Dr. Scott Peterson (Phoenix, AZ): Very nice job in presenting a very important topic. I was fascinated by the compliance rate, especially the improvement in your Program Director Dr. Dunn. In fact, it is obvious that you can teach an old dog new tricks! Dr. John Potts (Houston, TX): We cannot leave this program, this paper, without making comment congratulating Dr. Dunn on his improved compliance! Dr. Kory Jones (Dallas, TX): He was very proud of himself. He uses it against the residents repeatedly—let me tell you. Dr. Scott Peterson (Phoenix, AZ): Because of his improvement, have you gone ahead and expanded this to the rest of your faculty, the rest of the department? Dr. Kory Jones (Dallas, TX): Well, Dr. Dunn really and Dr. Mangram also participates a lot in our surgical clinic, but they are really the only 2 attendings that actually participate with the surgery clinic. So that is the only audits that we have done and the only evaluation that was done of this education program.
The Southwestern Surgical Congress
Practice management education during surgical residency Kory Jones, M.D., Ricardo A. Lebron, M.D., Alicia Mangram, M.D.*, Ernest Dunn, M.D. Department of Surgery, Methodist Health System, 221 W. Colorado, Pavilion 1, Suite 100, Dallas, TX 75208, USA KEYWORDS: Practice management; Resident education; Coding
Abstract BACKGROUND: Surgical education has undergone radical changes in the past decade. The introductions of laparoscopic surgery and endovascular techniques have required program directors to alter surgical training. The 6 competencies are now in place. One issue that still needs to be addressed is the business aspect of surgical practice. Often residents complete their training with minimal or no knowledge on coding of charges or basic aspects on how to set up a practice. We present our program, which has been in place over the past 2 years and is designed to teach the residents practice management. METHODS: The program begins with a series of 10 lectures given monthly beginning in August. Topics include an introduction to types of practices available, negotiating a contract, managed care, and marketing the practice. Both medical and surgical residents attend these conferences. In addition, the surgical residents meet monthly with the business office to discuss billing and coding issues. These are didactic sessions combined with in-house chart reviews of surgical coding. The third phase of the practice management plan has the coding team along with the program director attend the outpatient clinic to review in real time the evaluation and management coding of clinic visits. RESULTS: Resident evaluations were completed for each of the practice management lectures. The responses were recorded on a Likert scale. The scores ranged from 4.1 to 4.8 (average, 4.3). Highest scores were given to lectures concerning negotiating employee agreements, recruiting contracts, malpractice insurance, and risk management. The medical education department has tracked resident coding compliance over the past 2 years. Surgical coding compliance increased from 36% to 88% over a 12-month period. The program director who participated in the educational process increased his accuracy from 50% to 90% over the same time period. CONCLUSIONS: When residents finish their surgical training they need to be ready to enter the world of business. These needs will be present whether pursuing a career in academic medicine or the private sector. A program that focuses on the business aspect of surgery enables the residents to better navigate the future while helping to fulfill the systems-based practice competency. © 2008 Elsevier Inc. All rights reserved.
Surgical education has undergone radical changes in the past decade. For example, the introduction of laparoscopic surgery has required the implementation of a skills laboratory. Endovascular techniques have changed * Corresponding author: Tel.: ⫹1-214-947-2303. E-mail address: [email protected] Manuscript received May 6, 2008; revised manuscript August 13, 2008
0002-9610/$ - see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2008.08.008
how the residents are taught in the operating room. The use of the 6 competencies is an integral part of surgical training. An area that has met very little change is the education of the surgical residents in the business aspects of medicine. Few programs have a formalized program to teach the surgical residents proper coding and documentation. In a recent survey Fakhry et al1 stated that 85% of residents believed
K. Jones et al.
Practice management education
they were a novice at coding and billing. This is a significant issue for a resident setting up an office practice because reimbursement continues to decrease while office overhead increases. The young academic surgeon is not immune to this problem because surgical chairmen are now looking very closely at the billings of the young faculty members. Another problem to be met is the increasing scrutiny of documentation and subsequent coding for services linked to Medicare and Medicaid. In the recent past the Centers for Medicare and Medicaid Services have begun to audit academic institutions and teaching programs. Failure to adequately document services has the potential to result in huge penalties and repayments. The purpose of this article is to present our program, which has been in place over the past 2 years and is designed to teach the residents practice management. In addition, this program enables the residents to participate in the systems-based core competency.
100.0% 90.0% 90.0% 80.0%
88.0%
80.0% 70.0% 60.0% 61.0%
60.0% 50.0% 50.0%
47.7%
40.0%
36.2%
30.0% Residents
20.0%
Program Director 10.0% 0.0% 1
2
3
4
Figure 1 Quarterly evaluation of coding accuracy of the surgical residents and program director. ⽧, Residents; , program director.
Methods The Methodist Medical Center of Dallas has a graduate medical education program that incorporates 4 core programs: general surgery, internal medicine, obstetrics and gynecology, and family practice. The surgical practice management program is composed of 3 parts. The first part is a series of monthly lectures given by the hospital administrative staff. The residents of all the programs are invited to a 1-hour lecture given at noon. The lectures include topics such as an introduction to types of practices available, negotiating a contract, managed care, and marketing a practice. Resident evaluations were completed for each of the practice management lectures. The responses were recorded on a Likert scale,1–5 in which the lowest score corresponds to “information is not pertinent” and the highest score corresponds to “information very pertinent” (Table 1).
Table 1
879
Practice management lecture series
Practice management lecture series
Likert score
Documentation and Coding Guidelines Types of practices—advantages and disadvantages Finding a job Evaluating employment agreements and recruitment agreements Understanding malpractice insurance and risk management Billing, billing compliance, and accounts receivables management Managed care 101: understanding the basics Accounting 101: developing a practice performance and business plan Marketing your practice Investing and financial planning
4.1 4.4 4.3 4.8 4.8 4.2 4.0 4.2 4.1 4.4
The second part of the program consists of a series of morning 1-hour meetings with the surgery residents, dealing specifically with documentation and coding (Fig. 1). Both inpatient and outpatient coding is discussed. This format consisted of both didactic lectures combined with actual chart reviews. The institutional coding and compliance manager has an open dialogue with the residents to explain how and when certain codes and modifiers are to be used. The third part of the program involves active participation in the clinic setting with the residents and coding personnel. At the end of a patient encounter the program director and surgical resident present the chart to the coding and compliance manager who will agree or disagree on the level of service coded. The role of appropriate Evaluation and Management (E/M) service codes and modifiers are discussed. The second and third parts of this education program were evaluated through chart audits performed on a quarterly basis. The audit consists of 10 evaluation and management service codes per provider per quarter. The 10-chart sample is determined by a computerized random selection process from each provider’s total patient population during the specific quarter. The coding and compliance manager performs all audits and reports to the compliance committee. The compliance committee has set an 80% overall accuracy standard that all providers must meet. The 80% overall coding accuracy includes both undercoded claims and overcoded claims. The surgical residents were evaluated individually and as a group. The surgical program director was evaluated on an individual basis.
Results Resident evaluations were completed for each of the practice management lectures. The responses were recorded
880
The American Journal of Surgery, Vol 196, No 6, December 2008
on a Likert scale1–5 (Table 1). The scores ranged from 4.1 to 4.8 (average, 4.3). The highest scores were given to lectures discussing negotiation of employee agreements, recruiting contracts, malpractice insurance, and risk management. Chart audits were performed quarterly over a 1-year period. Surgical coding compliance for the residents increased from 36% to 88% over the 12 months. The surgical program director, who participated in the same education process, increased his accuracy from 50% to 90% over the same time period (Fig. 1). Some errors still persisted. Inpatient coding problems occurred in the nonsurgical patients who were managed medically. Only lower-level codes can be used daily on patients who are stable or making progress. The surgery residents tended to use higher-level codes based on possible case complexity. In the outpatient clinic coding errors were seen as a result of failure to document an adequate number of bullet points in the review of systems. This resulted in significant underbilling of provided services. The improvement in the surgical program director’s compliance was related to better documentation in both the inpatient and outpatient setting. Although the patients had been seen and progress notes by the residents were signed by the program director, the specific wording, “I have seen and examined the patient,” was not always included. Surgical notes defining staff participation were always in compliance and did not change during the survey period.
Comments For graduating surgical residents there is increased complexity and uncertainty when entering the business of medicine. Residents need to be aware of the ever-changing legal, organizational, managerial, and reimbursement issues. The practice management program at Methodist Hospital of Dallas has tried to address some of these concerns. The program aims at issues such as employment contracts, office operations and management, financial and personal management, regulatory issues, insurance processing, coding, and billing, among other important issues. Interestingly, although we have adapted the surgical curriculum to meet innovations in care such as laparoscopic surgery and endoscopic techniques, there has been little improvement in our education of the business aspects of medicine. Breitwieser et al2 in 1981 did a survey of 717 third-year family practice residents. Eighty-seven percent had no medical school lectures or seminars in the business of medicine. More than 66% of residents believed that they were unprepared in various office management topics.2 Ten years later, in 1991, Ridky and Bennett3 showed through a mailed survey of 8 academic surgery programs that 70% of past residents did not believe that they were well prepared in practice management issues. At the same time, a telephone survey of 117 academic medical centers showed that only
4% of surgery programs offered a formal course in practice management to their residents. The conclusion was that many graduating residents are spending valuable time at the beginning of their practice learning the basics of practice management.3 Unbeknownst to us at the time of implementation of our program, the suggested topics that Ridky and Bennett3 thought should be taught are indeed part of our management program. The problem has not gotten better over the past decade. Fakhry et al1 surveyed 5 surgical residency programs in 2007 and found that 85% of residents believed that they were inadequate at coding and billing. However, 92% of these residents believed that this was important to their practice. In addition, 80% of the attendings at these 5 institutions believed that this knowledge was valuable to their practice. These data are similar to the attitude reflected by our surgical residents. The attendance at monthly practice meetings has been high and the approval of the lectures has been very good (average Likert score, 4.3). Knowledge of E/M coding has a number of specific benefits. Physicians in both the private sector and academic divisions of general surgery are facing constant financial pressures. Kuo et al4 in 2003 looked at his own university general surgical division. They showed that substantial increased revenue could be generated from proper E/M coding and billing. Their conclusion was that E/M coding and billing were significantly underused in this patient population. This was similar to a prior study in 2001 by Ng and Lawless.5 They looked at the billing and coding practices of pediatric residents in outpatient clinics. The resident accuracy was 38% for acute care visits. Most errors were in undercoding for provided services. The loss of potential revenue was substantial. They believed that a residentstaffed clinic under these conditions would not be financially self-sufficient. We had the same problems in our outpatient clinic. Our initial resident coding accuracy was 36%, which is very similar to the 38% accuracy Ng and Lawless5 reported. Over a 12month period this improved to 88%. This improvement was only seen after a series of lectures (Fig. 1) and onsite chart review by the coding and compliance manager. The surgical program director saw an improvement in coding compliance from 50% to 90% over the same 12month period. The improvement was the result of better documentation of resident supervision. This is not an isolated problem to our institution. Howell et al6 in 1999 performed a survey of all emergency medicine (EM) residents taking the in-training examination. They had an 88% response rate. The EM residents recorded faculty supervision rarely. Twenty-five percent of residents “never” recorded faculty participation, whereas another 25% of EM residents recorded faculty involvement from 1% to 25% of the time.6 Centers for Medicare and Medicaid Services guidelines require evidence of faculty supervision. In the Howell et al6 study only 17% of EM residents documented faculty presence for procedures routinely. This has major
K. Jones et al.
Practice management education
implications for Medicare and Medicaid reimbursements. Federal audits have resulted in denied charges for a number of academic institutions. There are other reasons to provide accurate coding. An editorial by Mabry7 in 2007 stated that more accurate coding of procedures, comorbidities, and complications will provide better administrative data sets. This will enable more accurate measurements of patient risks and predict outcome. This may in turn potentially generate better diagnosis-related groups for hospital reimbursement.7 The American Board of Medical Specialties and the Accreditation Council for Graduate Medical Education and the Association of American Medical Colleges have now endorsed 6 primary competencies for graduate medical education. Systems-based practice is 1 of these 6 competencies. There are a number of components included in the systems-based practice such as understanding the health care organization, having knowledge of types of medical practices and delivery systems, and how to partner with health care managers and health care providers. The practice management program we have in place helps to satisfy this competency. The tracking of compliance improvement enabled us to grade success of the coding portion on the program. Personal communication with our graduating residents over the past 2 years has shown great satisfaction with the concept. They believe that the combination of the lecture series with practical every day billing and coding discussions has enabled them to make an easier transition into private practice. They also believed that the lecture series was helpful when creating a curriculum vitae and negotiating contract agreements. These lectures served as a guide to the resident beginning his practice.
Conclusions The graduating surgical resident today faces a multitude of business decisions when entering practice in either the private setting or academic medicine. Regardless of the type of surgical practice, financial issues will be permanent. Our program was established to help ease this transition. The American College of Surgeons has been an active participant and now provides a number of educational tools to help with coding and practice management. There is a need for surgical programs to address this issue early in the residency. This will allow the resident to assimilate this information over the length of his training rather than trying to learn these business skills during their first months in practice.
References 1. Fakhry SM, Robinson L, Hendershot K, et al. Surgical residents’ knowledge of documentation and coding for professional services: an opportunity for a focused educational offering. Am J Surg 2007;194:263–7. 2. Breitwieser D, Adye W, Arvidson M. Resident evaluation of current practice management training. J Fam Pract 1981;13:1063– 4.
881 3. Ridky J, Bennett T. Training surgery residents in group practice management. Med Group Manage J 1991;38:38 –9. 4. Kuo PC, Douglas AR, Oleski D, et al. Determining benchmarks for evaluation and management coding in an academic division of general surgery. J Am Coll Surg 2004;199:124 –30. 5. Ng M, Lawless ST. What if pediatric residents could bill for their outpatient services? Pediatrics 2001;108:827–34. 6. Howell J, Chisholm C, Clark A, et al. Emergency medicine resident documentation: results of the 1999 American board of emergency medicine in-training examination survey. Acad Emerg Med 2000;7:1135– 8. 7. Mabry CD. Surgical residents’ knowledge of documentation and coding for professional services: an opportunity for a focused educational offering. Am J Surg 2007;194:268 –9.
Discussion Dr. Jon Thompson (Omaha, NE): Dr. Jones and her colleagues are to be congratulated. They report that the practice management course was well received; however, the number of residents who actually participated in such training is not clear. Do you get a high attendance rate from the residents? Is it the time of day or of the format that would help you to be more successful? As you point out, what are the issues with billing and coding? Is it the timing of the documentation? You also mentioned a problem with not enough bullet points for review of systems or physical examination. Do you have an electronic medical record in your clinic setting? Have you done resident surveys or any other evaluations in these activities to better asses the educational impact? It certainly has been my impression, particularly with billing and coding, it takes a number of repeated lectures on the same topic until you start to get a satisfactory compliance. Finally, you conclude that this training is important early in residency. I would certainly agree with that in terms of the billing and coding documentation; however, my impression is that many of the practice management aspects become more relevant the closer you get to completing your training and thus should be more important at that time. Dr. Kory Jones (Dallas, TX): The first question—we actually had very good attendance. First of all, with the monthly lectures, it was given at lunch and all the residents were invited to attend. Any time you give free lunch to residents, I think you get a good turnout. We found a great deal of resident interest, especially in the upper-level residents. Of course, residents towards the end of their residency would come to these lectures more often. These were mandatory conferences, which we integrated into our mandatory basic science conferences. If we continue to do this all 5 years, which is what we intend to do, they have multiple opportunities to go to these lectures, which serves to reinforce the material. The coding personnel are always available and we see by the chart audits what we need to be concentrating on and so they will make themselves available to us at a later time in order to concentrate on those aspects. In the clinic, we do not have electronic records, but we have re-evaluated the forms that we use for documenting
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our patient encounters, which serves as a reminder for the residents. We have not formally evaluated this from the resident; however, I can just say personally it has helped me tremendously when I started my practice. My partners were pleasantly pleased they did not have to spend a lot of time trying to take me through some of the coding issues when I started and I was able to more easily start my practice and begin billing immediately rather than learning these things on the job. Dr. Steve Smith (Wichita, KS): Have you continued to follow the performance of the residents in regards to compliance in the past 12-month period? Has the rather dramatic improvement that you saw have been maintained throughout the longer period? You also mentioned a little bit about recurrent training. How often do you think that is going to be necessary to maintain the high levels of compliance that you presently have? And, final question, has the increase in compliance actually translated into a better financial performance for the department? Dr. Kory Jones (Dallas, TX): We have continued to perform the chart audits. This is ongoing within our program and we have continued to have better compliance numbers throughout the time period that we have been doing this. After that dramatic increase we have continued to be in the upper 80th percentile. Of course, preliminary interns may have a lower compliance rate because they are not paying much attention and they are not as involved in the process. But, their compliance has also improved.
Dr. Ernest Dunn (Dallas, TX): Kory, can I just answer the second part? She is now gone into private practice. But the numbers are still holding at about 90% in terms of compliance. In terms of increased revenue, it is hard to say because in Texas, our clinic runs about 30% self-pay so I think we are doing a better job, but realistically how much of that will transfer into increased income is up for debate. Dr. Scott Peterson (Phoenix, AZ): Very nice job in presenting a very important topic. I was fascinated by the compliance rate, especially the improvement in your Program Director Dr. Dunn. In fact, it is obvious that you can teach an old dog new tricks! Dr. John Potts (Houston, TX): We cannot leave this program, this paper, without making comment congratulating Dr. Dunn on his improved compliance! Dr. Kory Jones (Dallas, TX): He was very proud of himself. He uses it against the residents repeatedly—let me tell you. Dr. Scott Peterson (Phoenix, AZ): Because of his improvement, have you gone ahead and expanded this to the rest of your faculty, the rest of the department? Dr. Kory Jones (Dallas, TX): Well, Dr. Dunn really and Dr. Mangram also participates a lot in our surgical clinic, but they are really the only 2 attendings that actually participate with the surgery clinic. So that is the only audits that we have done and the only evaluation that was done of this education program.