Teaching Billing and Coding to Medical Students: A Pilot Study

Abstract

Complex billing practices cost the US healthcare system billions of dollars annually. Coding for outpatient office visits [known as Evaluation & Management (E&M) services] is commonly particularly fraught with errors. The best way to insure proper billing and coding by practicing physicians is to teach this as part of the medical school curriculum. Here, in a pilot study, we show that medical students can learn well the basic principles from lectures. This approach is easy to implement into a medical school curriculum.

SHORT COMMUNICATION

Teaching Billing and Coding to Medical Students: A Pilot Study

Jiaxin Tran1, David Cennimo2, Sophia Chen3 and Eric L. Altschuler1*

1Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ, USA; 2Department of Medicine and Pediatrics, Rutgers New Jersey Medical School, Newark, NJ, USA; 3Department of Pediatrics, Rutgers New Jersey Medical School, Newark, NJ, USA

Abstract

Complex billing practices cost the US healthcare system billions of dollars annually. Coding for outpatient office visits [known as Evaluation & Management (E&M) services] is commonly particularly fraught with errors. The best way to insure proper billing and coding by practicing physicians is to teach this as part of the medical school curriculum. Here, in a pilot study, we show that medical students can learn well the basic principles from lectures. This approach is easy to implement into a medical school curriculum.

Keywords: billing and coding; evaluation and management services; compliance; education; new curricular material

To access the supplementary material to this article please see Supplementary files under Article Tools online

Received: 16 May 2013; Revised: 13 June 2013; Accepted: 17 June 2013; Published: 12 August 2013

Med Educ Online 2013. © 2013 Jiaxin Tran et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution 3.0 Unported (CC BY 3.0) Licence (http://creativecommons.org/licenses/by/3.0/), permitting all non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Citation: Med Educ Online 2013, 18: 21455 - http://dx.doi.org/10.3402/meo.v18i0.21455

Complex billing practices cost the US health care system billions of dollars annually (1, 2). Coding for outpatient office visits [known as Evaluation & Management (E&M) services] is notoriously poor - with several Medicare audits of outpatient claim records reporting error rates as high as 91% (3). While the new generation of physicians is increasingly cognizant of gaps in their knowledge of proper documentation and coding (4), the existing medical school curricula have largely failed to address this deficit (5). This is unfortunate, as proper practices are best taught early, before bad habits form - making undergraduate medical training the logical place to introduce students proper coding and documentation. Towards this end, we have initiated a programme at our medical school to teach billing and coding to medical students, starting with the basic principles in second year and subsequent applications in later years.

After approaching directors of our school's second-year clinical skills course about teaching billing and coding, it was agreed that this represented an appropriate placement of such materials. Other faculties and the administration were supportive of the idea, and the addition of billing and coding was approved by our school's curriculum committees and, later, by the faculty council.

The objectives for students were to learn the basic principles of billing and coding and, specifically, to be able to successfully bill for outpatient office visits (E&M services). The lecture material was to be reinforced by the evaluation of write-ups and notes done during the second-year clinical skills course and, it was hoped, notes written during the third and fourth years also.

We prepared four 1-hour lectures on E&M billing and coding (see Supplementary Materials online) on the three aspects of billing and coding for E&M visits: (1) medical history; (2) physical examination; and (3) medical decision-making - along with a review lecture. Our initial plan was to give the first two lectures in the fall and the remaining two near the end of second year. However, due to Hurricane Sandy, the fall lectures were postponed until near the end of the clinical skills course.

While student's comments regarding associated lectures were generally positive, reflecting an interest in the topic, the short- and long-term effectiveness of our efforts remains to be rigorously established. In terms of learning outcomes, for example, simple knowledge recall of key elements may be validly assessed via 'traditional' exams containing single best answer, multiple choice questions (MCQs). However, measuring more advanced skills or knowledge application - such as those involved in the 'art' of actual coding - may require more complex formats, such as mock billing scenarios. Moreover, identifying a level of 'competent' performance expected of second-year students will likely also pose a challenge.

Incorporating 'medical administrative' content into already over-crowded undergraduate curricula is not without potential concerns. For example, completing regulatory (and other) paperwork needed to comply with current practice requirements is a primary driver of health care costs - making our health care delivery system among the most expensive of any industrialised nation. Arguably, for physicians, these tasks also constitute one of the least desirable aspects of modern medicine. As a result, exposing students early on to the underlying bureaucracy of medical practice could conceivably hasten documented declines in empathy across the undergraduate curriculum.

However, ensuring optimal and timely reimbursement vis-à-vis proper billing and coding is a necessary part of practicing medicine in a capitalist economy. Thus, given the small amount of curricular time needed - combined with encouraging student interest and 'uptake' of related material - we believe that integrating some content on billing and coding during undergraduate training may prove, in the long run, to be a beneficial skill.

Conflict of interest and funding

The authors have not received any funding or benefits from industry or elsewhere to conduct this study.

References

1. HHS, Inc. America's hidden healthcare crisis. National Managed Health Care Congress - Managed Care Leadership Conference. Washington, DC: HSS, 7-9 March 2005. pp. 1-16.

2. Centers for Medicare & Medicaid Services. Medicare fee-for-service 2011 improper payments report. Medicare FFS 2011 CERT Report; 2012. Available from: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/CERT/Downloads/MedicareFFS2011CERTReport.pdf [cited 8 March 2013].

3. Schulte F, Donald D. How doctors and hospitals have collected billions in questionable Medicare fees. Center for Public Integrity; 2012. Available from: http://www.publicintegrity.org/2012/09/15/10810/how-doctors-and-hospitals-have-collected-billions-questionable-medicare-fees [cited 8 March 2013].

4. Roberts JL, Ostapchuk M, Miller KH, Ziegler CH. What residents know about health care reform and what we should teach them. J Grad Med Educ 2011; 3: 155-61. PubMed Abstract | PubMed Central Full Text | Publisher Full Text

5. Cooke M, Irby D, O'Brien B. Educating physicians: a call for reform of medical school and residency. Stanford: The Carnegie Foundation for the Advancement of Teaching; 2010.

*Eric L. Altschuler

Department of Physical Medicine and Rehabilitation

Rutgers New Jersey Medical School

Newark, NJ

USA

Email: [email protected]