Table 1.

Literature on billing and coding summarized by author, origin, study purpose, study design, and results.

Authors	Origin	Purpose	Research design	Results
Cawse-Lucas et al. 1	The United States	To investigate the impact of Medicare Primary Care Exception (PCE) on resident coding practices.	A survey sent to Family Medicine (FM) residency program directors in a five-state region. The percentage of high-level codes was compared between residents and attendings using the chi-square analysis. Data from 125,016 visits from 337 residents and 172 faculties in 15 eligible FM residencies were analyzed.	Attending physicians coded higher level visits. The estimated revenue lost was 2558.66 per resident and 57,569.85 per year for the average residency in their sample.
Adams et al. 4	The United States	To recommend an approach for assessing potential risk, preventing improper billing, and improving financial management of a medical practice.	Lays out a training module for physicians.	E&M guidelines are updated periodically, and coding practices need to be updated accordingly to reflect new guidelines.
Adiga et al. 5	The United States	To determine “perceived, desired, and actual knowledge” of Medicare billing and reimbursement among internal medical (IM) residents compared with community IM generalist.	Survey of community and university PGY-2 IM residents from four geographical regions in the United States assessing: 1. Self-awareness. 2. Ability to correctly answer billing questions.	Participants disagree with the statement that they receive enough training about Medicare and agree that reimbursement should be taught. Residents scored significantly lower than general IM physicians on actual knowledge. Primary care track residents scored significantly lower on actual knowledge test than did categorical residents.
Al Achkar et al. 6	The United States	To assess the variation in billing patterns between resident and attending physicians considering provider, patient, and visit characteristics.	Retrospective cohort of established patient visits in outpatient FM clinic over 5 years. Used logistic regression methodology to identify variation and used Poisson’s regression to test sensitivity. A total of 116 residents and 18 attendings were reviewed.	After review, residents were shown to bill higher E&M codes less often when compared to attendings for comparable visits.
Andreae et al. 7	The United States	To assess recent pediatric graduates’ views on training for billing and coding during training.	National survey using AAP national database. 1200 generalist pediatricians and 1100 subspecialists were selected to receive a survey which asked them to rate their impression of the adequacy of their training program in teaching billing and coding.	Response rate was 76% for generalist and 77% for subspecialty. A total of 81% of generalist and 78% of subspecialist respondents indicated they could have used additional training in billing and coding.
Arora et al. 8	The United States	To assess AAP pediatric trainee’s thoughts about time spent documenting and need for education in billing and coding.	Pediatric residents and fellows who are members of AAP Section of Pediatric Trainees were sent a survey via email and hosted on Google Forms. Responses based on the Likert scale (1–5). There were 601 respondents.	A total of 62% of respondents had no prior training in billing and coding. A total of 263 respondents were involved in billing and coding of which 75% of respondents were not comfortable with billing and coding. Three out of four agreed billing/coding techniques should be part of medical education.
Austin and von Schroeder 9	Ontario, CA	To compare surgical resident and staff physicians on billing knowledge as well as explore experiences and opinions regarding billing and coding education during residency training.	Both groups completed 10 hypothetical scenario-based clinical billing assessments graded by professional billing experts. Responses were scored as correct (most appropriate), underbilled, overbilled, or incorrect. Post-test survey. Small sample size: 16 residents and 17 staff physicians at one center.	Staff physicians scored higher percentage correct on billing codes, underbilled codes, and had fewer missed billing codes. On the post-test survey, 100% residents and 79% physicians wanted additional education.
Faux et al. 10	Australia	Attempt to systematically map all avenues of education on Medicare billing and compliance in Australia and explore perception of teaching medical billing.	National cross-sectional survey assessing percentage of programs offering education course on billing. Sample size n = 57.	There was an 86% response rate with 70% stating they did not offer a course on billing. Remaining 30% offered a course, but 71% of these courses were vocational education providers. Survey concluded there was a lack of qualified educators and education is largely taught by medical practitioners rather than qualified educators who have expertise in administrative and legal aspects of Medicare.
Ghaderi et al. 11	The United States	To improve billing and coding in surgical residency outpatient practice.	A total of three separate 20-min didactic sessions were held prior to regular conference. One year pre-intervention compared to 1-year post-intervention.	They found an increase in higher level coding and billing accuracy comparable to national average post-intervention.
Varacallo et al. 12	The United States	To assess a group of orthopedic residents’ knowledge on documentation, billing, and ability to identify Medicare fraud.	Voluntary participation from two separate residency programs; n = 32. Residents completed a baseline assessment followed by a 45-min lecture, followed by post-test. Each resident asked to self-rate documentation and coding comfort level on Likert (1–5) scale.	Level of comfort increased with increasing post-graduate year (PGY); however, there was no difference in baseline scores on pre-test between junior and senior residents. The lecture significantly improved knowledge as assessed by the post-test.
Waugh 13	The United States	QI project to improve knowledge of billing within neurology residency and fellowship training.	Pre-intervention in which resident documentation and billing were analyzed. Followed by an intervention implementing dedicated curriculum to improve accuracy of documentation and coding. Implemented documentation tools. Analysis of resident documentation and billing for 15 months after initiation of intervention.	Pre-intervention: 56% of trainee-generated outpatient encounter notes had insufficient documentation to support level of billing. Study progressively eliminated note devaluation and increased mean level billed by US$34,313 per trainee per year.
Kapa et al. 14	The United States	To develop an instrument for billing in IM resident clinics, to compare billing practices among different resident levels, and to estimate financial losses from inappropriate resident billing.	A total of 100 random patient notes were assessed and scored by three different coding specialists, and billing codes were converted to US$ based on Medicare reimbursement list.	A total of 55% of assessed notes were underbilled by an average of US$45.26 per encounter, and 18% were overbilled by US$51.29 per encounter. The percentage for appropriate coding was 16.1% for PGY-1, 26.8% for PGY-2, and 39.3% for PGY-3.
O’Donnell and Suresh 15	The United States	Provide a policy statement from AAP on clinical documentation, direct future research and development for electronic media to improve health care delivery, and address challenges for efficient and effective documentation in pediatrics.	This policy statement provides recommendations for advocacy for development and advancement of pediatric electronic health records (EHR) functionality.	The needs of child health care documentation differ from adults, yet there has not been a defining EHR documentation for pediatric populations. There is a market for EHR development, however, because children represent a small percentage of overall healthcare usage, it may be difficult to engage vendors in pediatric-specific projects and EHR enhancement.
Caskey et al. 16	The United States	To examine how the transition to ICD-10-CM may result in ambiguity of clinical information and financial disruption for pediatricians.	ICD-9-CM codes were obtained from IL Medicaid for 1 year (2010) and were mapped to ICD-10-CM codes. Mappings were examined by pediatricians for clinical accuracy and financial analysis of findings conducted.	The diagnosis codes represented by information loss (3.6%), overlapping categories (3.2%), and inconsistency (1.2%) represented 8% of Medicaid pediatric reimbursement. This could translate to potential financial and administrative errors which necessitates attention to coding when transitioning to ICD-10-CM.
Chung et al. 17	The United States	To summarize the payer structure including CHIP, discuss the process by which radiologists receive reimbursement, explain process of using ICD-10-CM codes, and explore coding-related issues specific to pediatric radiology.	Explains payers of services, billing process, documenting clinical necessity of imaging services, use of ICD-10-CM codes, documenting imaging services provided, requesting reimbursement, and finally, the unique challenges for reimbursement in pediatric radiology.	Pediatric radiologists can improve coding accuracy and enhance revenue through proper documentation of clinical necessity and detailed description of the services provided with an understanding of the components required for correct billing.
Bala and Shelburne 18	The United States	To reduce the average monthly number of missed charges within two pediatric neurology clinics by 50% within 6 months.	Pre-intervention: looked at a 3-month period, 1255 encounters at two clinic sites. Intervention: 1. Electronic billing was mandated. 2. A formal tracking and feedback mechanism was created to educate providers about their own missed charges and facilitate accountability. Feedback was provided every 1–2 weeks via email. Providers could measure their own performance against de-identified peers.	At the beginning, the department was missing an average of 91 charges per month. A total of 25% of charges were created late or not at all. Denial of payment or non-payment resulted in US$9831.33 lost revenue per month. Post-intervention missed charges were reduced by more than 50% over a 6-month period to 26 missed charges per month.
Nguyen et al. 19	The United States	To implement a longitudinal method for teaching billing and coding within an FM residency.	Pre-test and post-test combined with monthly coding learning sessions implemented within academic curriculum.	There was no improvement in coding accuracy rates from baseline from didactic teaching.
Chiu et al. 20	The United States	To focus on opportunities for changes in state Medicaid programs resulting from the 2010 Patient Protection and Affordable Care Act.	Policy recommendations focus on the areas of benefit coverage, financing and payment, eligibility, outreach and enrollment, managed care, and QI.	Regardless of state variations in participation in the ACA Medicaid expansion, Medicaid will remain as the largest single insurer of children. Governmental health policy on both state and federal levels has not adequately met the needs of children; however, the AAP has developed a framework to readdress these deficiencies to enhance care and outcome.

QI: quality improvement; AAP: American Academy of Pediatrics; ICD-10-CM: International Classification of Disease, Tenth Revision, Clinical Modification; ICD-9-CM: International Classification of Disease, Ninth Revision, Clinical Modification; ACA: Affordable Care Act.