Objective:

To enhance neurology residents' understanding of the Centers for Medicare & Medicaid Services  Evaluation and Management (E/M) guidelines and their impact on clinical documentation and reimbursement

Background:

Accurate clinical documentation is essential for both high-quality patient care and appropriate reimbursement. Insufficient familiarity with E/M guidelines can lead to delays, reductions, or denials in reimbursement. Despite its critical importance, the complexities of E/M documentation are often underemphasized in medical education. With recent revisions to these guidelines, residency programs must integrate comprehensive training on documentation and its direct financial implications, ensuring the development of well-rounded physicians prepared for practice

Design/Methods:

A structured, multi-phase intervention was implemented within the Neurology residency program at the University of Kentucky. The first phase comprised two live, hour-long Zoom didactic sessions on in-patient and out-patient E/M documentation, incorporating pre- and post-session surveys to assess baseline knowledge and improvements. The second phase involved a half-day bootcamp, utilizing simulated patient case scenarios to provide hands-on experience in accurate documentation. Pre- and post-bootcamp assessments were conducted using commonly encountered clinical cases, evaluating participants' coding proficiency

Results:

Twelve residents from all postgraduate years participated in the survey. Initial assessments revealed notable gaps in knowledge and low confidence in applying E/M coding principles. After the didactic sessions, residents' comfort with coding improved, with 66.7% reporting an understanding of most of the concepts post-intervention, compared to 75% indicating minimal knowledge beforehand. Post-bootcamp assessments reinforced these improvements, showing significant gains in both understanding and practical application of coding guidelines.

Conclusions:

These findings underscore a significant educational gap in E/M documentation among neurology residents, which can be effectively addressed through targeted interventions. Comprehensive training, incorporating both theoretical and practical components, significantly improves knowledge and confidence. Given the dynamic nature of E/M guidelines, residency programs should incorporate ongoing education to ensure residents’ continued proficiency in accurate documentation and reimbursement practices.