SHM Converge Scientific Abstract ePoster Gallery-Improving Medical Documentation in Residency Education With Regular Coding Audits

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This retrospective study examined inpatient documentation and billing accuracy in a newly accredited internal medicine residency program at a rural Indiana hospital. The authors reviewed adult general medicine and ICU teaching-service admissions from July 2021 to June 2022, with clinical coders auditing 5% of encounters each month. They assessed whether resident documentation supported the billed CPT level of service and downgraded charges when required documentation elements were missing.<br /><br />Out of 10,231 total charges, 511 were audited and 82 were found deficient, for an overall error rate of 16%. The most common documentation problems were incomplete review of systems (52% of deficient charts), missing discharge management time (24%), and missing past family history (17%). Other issues included incomplete social history, incorrect medical decision-making, insufficient history of present illness, missing chief complaint, inadequate physical exam, and missing past medical or surgical history.<br /><br />To address these errors, the program introduced a structured peer education curriculum, a coding guidelines sheet, live teaching during conferences, real-time feedback during inpatient rotations, and updated discharge templates to better capture discharge time.<br /><br />The authors conclude that routine coding audits can improve residents’ understanding of billing rules, strengthen medical documentation, and support ongoing peer education. They emphasize that accurate code selection is the provider’s responsibility and should align with CMS guidelines.

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 Medical Billing

Concept Medical Coding

Concept CPT Code

Concept CMS Billing Guidelines

Distinguished Non-Finalist

Presenter Organization Southwest Indiana Internal Medicine Residency (Indiana University)

Presenting Author Keir F. MacKay

Track Quality Improvement

Keywords

inpatient documentation

billing accuracy

resident education

CPT coding

medical coding audits

internal medicine residency

documentation deficiencies

CMS guidelines

discharge management time

peer education

Medical Documentation

Medical Billing

Medical Coding

CPT Code

CMS Billing Guidelines