Expanding the objective structured clinical examination (OSCE) to teach documentation, coding and billing

Dear Sir

The Objective Structured Clinical Examination (OSCE) can augment traditional written tests to assess medical trainees’ clinical competencies. Coding and billing is poorly taught and inadequately evaluated, and trainees report feeling unprepared for this aspect of medicine (Fakhry et al. 2007). One program incorporated documentation and billing exercises as part of an abbreviated 2-case OSCE and noted instances of under-coding, over-coding and even insurance fraud (Franzese 2008). We developed a formative geriatrics fellowship OSCE to teach principles of documentation, coding, and billing and to inform curricular improvement.

The OSCE blueprint included geriatric syndromes, end-of-life care, geriatric practice sites and varying patient complexity (robust, frail and dying). Fellows encountered six 30 minute scenarios, followed by 15 minutes to complete documentation, coding and billing. Performance checklists (history, exam and management skills) were completed by standardized patients and geriatrics faculty to provide individualized feedback.

Afterwards, fellows participated in a didactic session that modeled application of compliance principles to the six cases. Fellows received sample documentation for each case – including audit forms using Medicare guidelines highlighting key elements of the history, physical exam and medical decision making that determined billing. Fellows compared these samples with their documentation, coding and billing submissions.

Blueprinting the examination using key competencies, care locations and patient complexity guided creation of a highly-relevant examination. We identified deficits in attaining relevant history (alcohol abuse in elders) and exam findings (pressure ulcers) that affected documentation. Most fellows lacked understanding of basic compliance concepts that practicing geriatricians encounter – supplying rich opportunities for individual and program improvement. This experience highlighted the value of using the OSCE to teach documentation, billing and coding principles which support fellows’ transition from learners to independent practitioners.