Original Article

Does the Use of Standardized History and Physical Forms Improve Billable Income and Resident Physician Awareness of Billing Codes?

Authors: Scott J. Sprtel, MD, Jonathan A. Zlabek, MD


Objectives: Resident physician knowledge of financial reimbursement guidelines for patient encounters is limited. We determined whether the use of standardized history and physical examination forms by residents for hospital admissions plus a brief lecture would increase the level of billing codes, increase billable income, and increase resident awareness of billing guidelines.

Methods: Residents used history and physical examination forms after a brief documentation lecture. Pretrial and posttrial surveys measured awareness of billing guidelines. The admission billing codes for a 6-month period were obtained, and the percentages were compared with a control 6-month period.

Results: There was an absolute increase of 14.5% in the highest code between the two study periods (P < 0.0001). Billable income increased by $10,385. Resident documentation awareness also increased (P < 0.001).

Conclusions: The use of history and physical examination forms, combined with a brief lecture, significantly increased the percentage of highest billing codes, which increased billable income. Resident awareness of documentation requirements significantly improved.

Key Points

* The documentation requirements of resident physicians in teaching settings are important and unique.

* A standardized history and physical form can be used as a tool by residents to help increase billable income for their institution.

* This form can also be used to increase resident awareness of documentation requirements.

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