title: Teaching residents coding and documentation: effectiveness of a problem-oriented approach.
abstract: OBJECTIVE
  We sought to assess the effectiveness of a problem-oriented approach to teaching residents accurate coding and documentation of ambulatory gynecology visits.
  
  
  METHODS
  This was a pilot before-and-after study. Nine resident volunteers underwent 4 individual instructional sessions on coding and documentation with a trained faculty member over 6 weeks. Outcomes were assessed by comparing the appropriateness of procedure and diagnostic codes billed in participant continuity clinic prior to and in the 6 to 9 months following the intervention.
  
  
  RESULTS
  Following the intervention, participants demonstrated an increase in the accuracy of coding the correct category of the evaluation and management service, an increase in the appropriate use of modifiers, and a decline in undercoding errors.
  
  
  CONCLUSIONS
  Problem-oriented interactive learning appears to be an effective method of teaching residents proper coding and documentation.
authors.affiliation: Division of Advanced Laparoscopy and Gynecologic Surgery, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, USA.
authors.forename: Sawsan
authors.initials: S
authors.lastname: As-Sanie
authors.forename: Denniz
authors.initials: D
authors.lastname: Zolnoun
authors.forename: Mary Ellen
authors.initials: ME
authors.lastname: Wechter
authors.forename: Georgine
authors.initials: G
authors.lastname: Lamvu
authors.forename: Frank
authors.initials: F
authors.lastname: Tu
authors.forename: John
authors.initials: J
authors.lastname: Steege
mesh_terms: D005240:Feasibility Studies; D006176:Gynecology / Q000193:education*; D049228:Healthcare Common Procedure Coding System; D007396:Internship and Residency / Q000592:standards*; D008501:Medical Records, Problem-Oriented; D009774:Obstetrics / Q000193:education*; D010865:Pilot Projects