Experimental Curriculum: Team-Based Learning for New AMA Charting and Coding Guidelines

The American Medical Association Revisions to the Current Procedural Terminology (CPT) codes for evaluation and management (E/M) kicked into effect this year for emergency department E/M services, making it paramount that residents apply the new guidelines when writing the medical decision-making portion of their charts.

Several associations, including ACEP, have offered various educational modalities including webinars and conferences, but it is of utmost importance that EM residency programs continually incorporate charting and coding education in their own curricula for new residents. A pedagogical modality that we encourage is team-based learning (TBL) offering emergency department case studies to illustrate the new documentation guidelines.

Our curriculum was delivered at one academic institution’s EM residency program, with 31 residents and 18 faculty and APP learners attending a TBL reimbursement workshop. Response to the exercise was overwhelmingly positive, with participants showing an increase in comfort with understanding and placing the 6 different E/M Current Procedural Terminology codes commonly used in EM.

The Accreditation Council for Graduate Medical Education (ACGME) has recognized the importance of residents understanding charting and coding by promoting educational activities involving charting and coding in the core competency system-based practice (SBP).¹ Competency in SBP requires that residents “demonstrate an awareness of and a responsiveness to the larger context and system of health care.”²

Despite this including charting and coding skills, numerous studies suggest a need for improved education in the area, with one study showing that only 15% of residents understand what an E/M code is and 74% feel they did not receive adequate education in charting and coding skills during residency.^2,3,4,5

While institutions have used multiple pedagogical approaches, the best method for teaching charting and coding is not clear.^6,7

To address the lack of a standardized charting and coding educational method at our institution, we incorporated charting and coding skills as part of our health policy curriculum. We used Kern’s 6-step approach to curriculum development, widely applied to multiple specialties and training within medical education, as we created a curriculum template for teaching the necessary charting and coding skills ^8,9

Table 1 summarizes Kern’s framework, outlines key aspects of our curricular design, and includes supporting educational evidence.

Table 1: Charting and Coding Curriculum Development Using Kern’s 6-Step Framework

Due to restrictions secondary to the COVID-19 pandemic, all residency didactic sessions were conducted virtually in 2020 when the original version of our TBL reimbursement exercise was conducted. We are currently swapping the content to teach the new 2023 documentation guidelines; however, the format remains identical to what we describe below. We dedicated 3 hours of didactic time for the Zoom® workshop. Learners were divided into heterogeneous 4- to 6-member teams incorporating learning at all levels of training into each group. EM faculty members either served as facilitators or observed and shared input.

In preparation for the TBL session, faculty members selected a preparatory charting and coding document and developed the curricular readiness assurance test consisting of 8 multiple-choice style questions (Appendix A). Prior to the TBL sessions, residents were expected to read the preparatory document (Appendix B) and complete a pre-curriculum survey. The preparatory document was freely available.

Each resident then participated in the TBL activity outlined in Table 2. The sessions included the 7 key TBL elements according to Haidet et al and were conducted using the standard TBL structure.¹⁰

Immediate Feedback
Faculty members provided immediate feedback after the group readiness assurance test to reinforce baseline knowledge and clarify discrepancies or misunderstandings. Answers to the readiness assurance test are included in Appendix C. A facilitator was also available for immediate feedback and clarification during each case-based discussion.

Team Application Activities
To develop team application activities, faculty members submitted de-identified cases that were used for case-based discussion during the traditional TBL small-group sessions (Appendix D) accompanied by small-group exercise tasks (Appendix E). Session materials are available in the appendix section. The small-group exercise tasks met the 4S criteria (i.e., significant problem, same problem, specific choice, simultaneous reporting) of a typical TBL: Teams worked on the same significant problem and selected specific choices simultaneously.^{11, 12}

There were 4 sample charts, and each was accompanied by an exercise task consisting of 8 multiple-choice options for each question. Teams were instructed that there was one correct answer for each, which encouraged commitment to an answer choice. Teams moved through one vignette at the same time. Approximately 10 minutes per case were allowed to debate answers within teams, after which each team committed to an answer that was discussed with the facilitator. The facilitator then spent 5 minutes probing the team to highlight important and salient points in the cases. Then the correct answer was revealed and discussed. Answers to the small-group cases and exercises are included in Appendix F and Appendix G, respectively.

Facilitation Schema

Table 2: Session Timeline

Evaluation
The pre-curriculum and post-curriculum survey represented the primary method used to evaluate the effect of the curriculum on improving charting and coding skills. The pre-curriculum survey information was adopted from the previous year’s health policy curriculum survey, which contained self-reported comfort for the charting and coding module based on a 100-point visual analogue scale via an anonymous SurveyMonkey distribution. The same survey was distributed after the curriculum with the addition of open-ended questions to assess strengths and areas for improvement. Survey results were not tracked to individual learners.

In July 2020, 29 individuals from our residency program responded to the pre-test survey with 1 nonresponse to the questions pertaining to reimbursement, charting, and coding. Thirty-one residents and 18 faculty and APP learners attended the TBL reimbursement workshop on July 29, 2020. Of the attendees, 10 (9 residents and 1 APP fellow) responded to the post-test survey.

To test whether the curriculum was meeting its goals for our learners, we looked at the 28 respondents to the curriculum pre-test (respondents comprised 1 faculty member, 2 APPs, and 25 residents). This represented almost two-thirds of our residents at that time (Table 3).

Prior to TBL, learners self-rated their comfort with understanding the 6 different evaluation and management commonly used in EM as 29.6 out of 100 (95% CI: 18.4, 40.9). Following the reimbursement TBL exercise, participants graded their comfort as 74.2 out of 100. This represents a statistically significant 44.6-point increase (p<0.0001).

Discussion
Despite ACGME recommendations to incorporate coding and charting education into EM residency training, there is no universally accepted method for such education, and most graduating physicians do not feel adequately prepared.^3,4,5

Our survey results corroborate previously published reports of medical trainees’ attitudes toward their preparation with billing and coding. Prior to our workshop, fewer than one-third felt that our current curriculum provided them with an understanding of evaluation and management (E/M) codes, with even less comfortable submitting billing charges. Providing a 3-hour workshop was enough to make learners feel more knowledgeable and comfortable with E/M code and payment models.

Residents enjoyed the format, stating that the workshop was effective, a worthwhile addition to the curriculum, and “a very effective way to communicate these points when compared to standard lecture.” Attendees also viewed the workshop as a “necessary session for us each year” and a “great introduction into the billing process and would like to get further smaller sessions through the year if possible.”

Conclusions
With the introduction of the new 2023 coding requirements, we plan to repeat this effective pedagogical method. To our knowledge, this is the first description of a TBL approach to resident billing and coding education. This approach has shown to be successful in teaching documentation and coding, fostering our residents’ competency in Systems-Based Practice.^6,13

We believe the TBL methodology increased learner satisfaction and engagement in comparison to previously used passive learning strategies and found that our learners self-reported significant improvements in their knowledge as a result of our curriculum. We recommend more widespread use of active learning methodologies to teach “nontraditional” components of the curriculum, such as documentation and coding.

The authors would like to acknowledge the following physicians for their assistance on this project: Emily Hirsh, MD, Department of Emergency Medicine, Emory University; Stan Wu, MD, Department of Emergency Medicine, Baylor College of Medicine; and Tyson Pillow, MD, Department of Emergency Medicine, Baylor College of Medicine.

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