Residency often prioritizes clinical skills over the minutiae of coding and documentation. Although neurology residents at the VAMC are responsible for selecting appropriate encounter information that will translate directly to billing and accurate reimbursement, they receive no formal training for this. Based on preliminary data from our institution, we discovered that residents entered information incorrectly 69% of the time. We devised a quality improvement project to improve documentation and coding. 

A pre-intervention survey was sent to all neurology residents. The survey assessed knowledge on topics such as “service connection.” Respondents also provided feedback on how they learned to document at the VA. The pilot intervention was provided to PGY-2s at class-specific orientation in July at the start of the 2020 academic year, and it included a live PowerPoint presentation with figures outlining which boxes required selection as well as education on how to select a level of billing. A post-intervention survey will be sent to all residents after a program-wide didactic on documentation.  

ºÃÉ«ÏÈÉú on appropriate documentation and coding with a structured intervention improved the accuracy of encounter completion among neurology residents at the VAMC. This could be generalized to any institution that partners with a local VA facility.