SHM Converge Scientific Abstract ePoster Gallery-A Retrospective Study of Economic Impact of Insufficient Medical Documentation

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This retrospective study examined whether insufficient resident documentation caused financial loss in a newly established internal medicine residency at a 158-bed rural Indiana hospital. Researchers reviewed inpatient encounters from July 2021 to June 2022 on teaching services (ICU and general medicine). Clinical coders audited 5% of randomly selected charts using CMS billing guidelines and downgraded CPT codes when documentation was incomplete.<br /><br />Out of 10,231 total charges, 511 were audited and 81 had deficiencies, an error rate of 16%. Common problems included missing review of systems, past/social/family history, medications, physical exam elements, and chief complaint documentation. The most frequent downgrade was from CPT 99223 to 99221.<br /><br />In the 5% sample, documentation-related code downgrades resulted in a revenue loss of $5,068.98 to $5,551.34, depending on whether each wRVU was valued at $42 or $46. Extrapolated across all encounters, the estimated total annual revenue loss was approximately $101,379.60 to $111,026.80.<br /><br />The authors implemented resident education tools and ongoing monitoring to improve documentation quality. They conclude that inadequate medical documentation can lead to substantial revenue loss and that basic billing and coding education in graduate medical education may reduce errors, improve chart quality, and positively affect hospital finances.

Asset Subtitle

Keir F. MacKay

Meta Tag

Author List Devon Fetters, Jay Patel, Keir F. MacKay, Niranjan Thothala, Sumender Sharma

Category Research

Concept Medical Documentation

Concept Resident Documentation

Concept Patient Care

Concept CPT Code

Concept Charting Deficiency

Distinguished Non-Finalist

Presenter Organization Southwest Indiana Internal Medicine Residency (Indiana University)

Presenting Author Keir F. MacKay

Track Quality Improvement

Keywords

resident documentation

revenue loss

medical coding

CPT downgrade

internal medicine residency

billing guidelines

chart audit

documentation deficiencies

graduate medical education

hospital finances

Medical Documentation

Resident Documentation

Patient Care

CPT Code

Charting Deficiency