Study highlights coding discrepancies between medical student and physician documentation
Findings from a retrospective study recently published in the Journal of Surgical Education show that medical students may be more likely than faculty members to document low levels of service for E/M office visits.
To assess the coding accuracy of medical student documentation, physician researchers conducted a retrospective chart review for outpatient visits for a thoracic surgery clinic in a large academic medical center between 2014 and 2016.
Reviewed cases included 80 E/M visits for new and returning patients requiring a complete history and physical exam and 20 postoperative evaluations documented by both a faculty member and a medical student. Most encounters (59% of reviewed cases) were for patients diagnosed with malignancies or lung cancer (36% of reviewed cases).
Faculty notes were composed by one experienced thoracic surgeon, and students’ notes were composed by third-year medical students.
Of the reviewed encounters for new and returning patients, 93% of faculty documentation was coded as level 4 and 7% as level 3. Only 29% of student documentation was coded as level 4, with 64% coded as level 3, 5% coded as level 2, and 2% miscoded as a postoperative visit due to lack of detail. The median level of service for the surgeon was level 4 whereas the median level of service for the students was level 3.
Researchers identified three main reasons for the students’ tendency to report lower levels of service:
- Documentation of low medical decision making
- Failure to adequately document tests or studies ordered
- Too few details included in the documentation of history of present illness, review of systems, past family and social history, and physical exam
Compared to faculty documentation, student documentation was also more likely to include ICD-10-CM diagnoses from the category “other” as well as secondary and tertiary diagnoses. ICD-10-CM code assignment was concordant between students and faculty for only 31% of documented cases.