Send to

Choose Destination
See comment in PubMed Commons below
Orthopedics. 2012 Nov;35(11):e1655-8. doi: 10.3928/01477447-20121023-26.

Level of billing as a function of resident documentation and orthopedic subspecialty at an academic multispecialty orthopedic surgery practice.

Author information

Department of Orthopaedic Surgery, University of Arizona Medical Center, Tucson, Arizona, USA.


Documentation, coding, and billing for physician-patient encounters have evolved over time and have significant variability. Appropriate and complete documentation of these encounters can contribute to the financial viability of private and academic medical centers. The objectives of this study were to assess the financial effect of documentation on billing and to compare the authors' institution's distribution of billing level compared with Medicare normative data. Four orthopedic surgery subspecialty clinics were evaluated at a university outpatient clinic over a 1-year period. A single full-day clinic per week was used for each subspecialty. Residents dictated the majority of the reports. All reports were transcribed by medical transcriptionists and coded by certified professional coders. The sports medicine subspecialty generated the highest volume of patient clinic visits, followed by foot and ankle, trauma, and spine (P<.01). The majority of the reports were billed at level 3 (P<.05). Significant differences existed between subspecialty and percentage distribution of billing level (P<.05). Compared with Medicare normative data, a significantly greater percentage of level 3 reports and a lower percentage of level 2 and 4 reports existed in the orthopedic practice (P<.01). The estimated loss of revenue from the fewer level 4 reports was $81,281.11 for 1 year. These findings highlight the need for greater educational interventions to improve provider documentation, coding, and billing. The effect of new electronic medical record systems that prompt providers to include key evaluation and management components will likely affect practices and warrant further analysis.

[Indexed for MEDLINE]
PubMed Commons home

PubMed Commons

How to join PubMed Commons

    Supplemental Content

    Full text links

    Icon for SLACK Incorporated.
    Loading ...
    Support Center