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Author Notes:

Correspondence: Kenan W. Yount, M.D., M.B.A. Division of Thoracic & Cardiovascular Surgery, University of Virginia 1218 Lee St. P.O. Box 800679 Charlottesville, VA 22908 kenan@virginia.edu, Telephone: 434-982-0332 Fax: 434-982-3885

The authors would like to thank the residents and faculty of the departments of surgery at the University of Virginia, University of Michigan, Vanderbilt University, Columbia University, Emory University, and Stanford University for their participation in the survey.

The authors also thank Debra Benson and colleagues for contributing their expertise on billing, coding, and documentation.


Research Funding:

None declared


  • Science & Technology
  • Life Sciences & Biomedicine
  • Cardiac & Cardiovascular Systems
  • Respiratory System
  • Surgery
  • Cardiovascular System & Cardiology
  • Surgical residents
  • Consultation codes
  • Services
  • Physicians
  • Speciality
  • Work
  • Time
  • Care

Resident Awareness of Documentation Requirements and Reimbursement: A Multi-Institutional Survey


Journal Title:

The Annals of Thoracic Surgery


Volume 97, Number 3


, Pages 858-864

Type of Work:

Article | Post-print: After Peer Review


Background: The current economic environment necessitates efforts to prevent avoidable losses in clinical revenue in academic cardiothoracic surgery programs. Inadequate documentation frequently results in delayed, denied, or reduced reimbursement. With the recent increase in integrated residency programs, documentation and compliance are becoming increasingly dependent on junior residents; however, their understanding of reimbursement and documentation guidelines is currently unknown. Methods: An electronically distributed, multi-institutional survey of 6 general and subspecialty surgery programs was conducted consisting of open-ended numeric estimation of Medicare reimbursement for various levels of patient encounters. Closed-ended questions were used to assess resident knowledge of documentation requirements, accompanied by self-estimated compliance with those requirements. Results: Thirty-seven percent (n = 106) of residents completed the survey. Most residents (77%) believe they play the primary role in documentation; however, knowledge of and compliance with higher level documentation practices range from 19% to 78% and 41% to 76%, respectively. On average, residents overestimate Medicare reimbursement of lower level encounters by as much as 77% and underestimate higher level encounters by as much as 38%. In many cases, the standard deviation of residents' estimates approaches the actual reimbursement value. Conclusions: Residents have a limited knowledge of documentation requirements. Self-reported compliance, even when guidelines are known, is low. Estimation of financial reimbursement is extremely variable. Residents overestimate reimbursement of lower level encounters and underappreciate reimbursement at higher levels. Ensuring appropriate reimbursement for services rendered will require formal cardiothoracic resident education and ongoing quality control.

Copyright information:

© 2014 by The Society of Thoracic Surgeons.

This is an Open Access work distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (https://creativecommons.org/licenses/by-nc-nd/4.0/).
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