Does the use of standardized history and physical forms improve billable income and resident physician awareness of billing codes?
OBJECTIVE
Resident physician knowledge of financial reimbursement guidelines for patient encounters is limited. We determined whether the use of standardized history and physical examination forms by residents for hospital admissions plus a brief lecture would increase the level of billing codes, increase billable income, and increase resident awareness of billing guidelines.


METHODS
Residents used history and physical examination forms after a brief documentation lecture. Pretrial and posttrial surveys measured awareness of billing guidelines. The admission billing codes for a 6-month period were obtained, and the percentages were compared with a control 6-month period.


RESULTS
There was an absolute increase of 14.5% in the highest code between the two study periods (P < 0.0001). Billable income increased by $10,385. Resident documentation awareness also increased (P < 0.001).


CONCLUSIONS
The use of history and physical examination forms, combined with a brief lecture, significantly increased the percentage of highest billing codes, which increased billable income. Resident awareness of documentation requirements significantly improved.
Sprtel
Scott J
SJ
Department of Internal Medicine, Gundersen Lutheran Medical Center, La Crosse, WI, USA.
Zlabek
Jonathan A
JA
D014487:Centers for Medicare and Medicaid Services, U.S. / Q000592:standards; D004282:Documentation; D005568:Forms and Records Control; D019983:Guideline Adherence; D006801:Humans; D007344:Insurance Claim Reporting / Q000592:standards*; D007396:Internship and Residency; D008487:Medical History Taking; D010808:Physical Examination; D012015:Reference Standards; D018709:Statistics, Nonparametric; D014481:United States; D014922:Wisconsin