A National Survey of Medical Coding and Billing Training in United States Dermatology Residency Programs

June 2018 | Volume 17 | Issue 6 | Original Article | 678 | Copyright © June 2018

Karin Blecher Paz MD,a Caroline Halverstam MD,a Alexandra K. Rzepecki BS,b and Beth N. McLellan MDa

aAlbert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY bUniversity of Michigan Medical School, Ann Arbor, MI

BACKGROUND: Due to frequent changes in medical coding systems, billing for outpatient visits through Evaluation and Management (E & M) services has become increasingly complicated. As a result, physicians often bill improperly, costing the United States health care system billions of dollars annually. Despite the importance of proper documentation, medical coding and billing is largely ignored during residency training. OBJECTIVE: Assess the exposure to and quality of medical coding and billing training in dermatology residency programs. METHODS: A questionnaire was distributed to dermatology programs in the United States consisting of questions pertaining to didactic education for, experience with, and resident knowledge of medical coding and billing. RESULTS: 138/443 dermatology residents participated (31.2% response rate). 79% of residents reported receiving some type of formal training. Nearly 89% reported personally billing patient visits to some degree, with 41.3% billing for 100% of outpatient visits. Over 75% of residents were able to answer basic billing questions and 70% correctly billed a patient visit when given a complex clinical scenario. Despite these results, only 37% of residents reported feeling confident in their billing abilities. Lastly, 94.9% of respondents believed medical coding and billing should be integrated into dermatology training curriculums. CONCLUSIONS: The majority of dermatology residents have opportunities to learn medical coding and billing through didactics and clinical experiences. Many residents were able to answer correctly questions that tested their basic knowledge of E&M coding. These results are encouraging and reflect the recognition of the importance of medical coding and billing training during residency. J Drugs Dermatol. 2018;17(6):678-682.


Complex billing practices cost the United States health care system billions of dollars annually.1,2 Due to frequent changes in coding systems, coding modifiers, and over 70,000 codes (ICD-103), coding for outpatient office visits (Evaluation and Management [E&M] services) has become increasingly complicated.4 As a result, the accuracy of E&M coding is poor, with Medicare audits reporting error rates as high as 91% for outpatient claims.1,5 In 2012, physicians billed $29.6 billion dollars in improper payments.6 Part of this problem may stem from the lack of medical coding and billing education during residency training across all medical and surgical subspecialties. One cross-sectional study of family medicine residencies across the Northwest United States reported an annual estimated revenue loss of $481,654 due to improper billing by residents.7 In addition, 62% of orthopedic residents reported no formal medical coding and billing training during residency.8 This is despite the fact that coding and billing is included in the Accreditation Council for Graduate Medical Education’s (ACGME) 6 core competencies.9 To our knowledge, very few studies examine medical coding and billing training during residency, and no previous studies have examined medical coding in dermatology residency curricula. Despite the integration of medical documentation in the 2014 ACGME Dermatology Milestone Project,9 we suspect that there is a lack of medical coding and billing education within dermatology residency curricula. In this study, we hope to examine the degree of medical coding and billing training during dermatology residency by elucidating the didactic and clinical experience, knowledge, and personal reflections of current dermatology residents.


To assess the exposure to and knowledge of outpatient coding and billing we developed a 19-item questionnaire that was sent to current dermatology residents affiliated with an ACGME-accredited program in the United States. The 19-item questionnaire was derived from clinical and academic experiences and included definitions and case examples that focused on basic concepts of billing. In addition, residents were asked about their personal exposure to medical coding and billing with regards to formal education, informal teaching from attendings, and hands-on experience during patient encounters. These questions were meant to characterize the billing training received during dermatology residency. Some questions provided the opportunity for multiple answers. Institutional Review Board (IRB) permission for this study was granted from the Albert Einstein College of Medicine, Bronx, NY.