COMMENTARY
Commentary on “Discordance in Current
Procedural Terminology Coding for Foot
and Ankle Procedures Between Residents
and Attending Surgeons”
Teaching the “business” of medicine, in the past, was
considered inappropriate, but that was when the business
of medicine was rather simple. Since the mid-1980s, and
especially since the Federal Government levied heavy fines
on some prestigious Academic Medical Centers for coding
violations, there has been an increase in need to teach
proper coding of operative cases using Medicare’s Current
Procedural Terminology coding requirements. The Accred-
itation Council for Graduate Medical Education expects
residents to be taught how to properly code.
The purpose of the study conducted by Murphy and
associates titled “Discordance in Current Procedural Ter-
minology Coding for Foot and Ankle Procedures Between
Residents and Attending Surgeons” was to examine the
concordance of coding foot and ankle cases between
residents and attending physicians and to investigate both
residents’ and attending physicians’ perceptions, habits,
comfort, and proficiency with coding. They found that
the residents were uncomfortable with their coding ability,
whereas the attending physicians were comfortable. They
also found low concordance in coding between the 2 groups.
The authors give 3 possible explanations. All 3 assume that
the attending physicians’ coding was correct or at least closer
to correct and the residents’ coding was incorrect or more
incorrect compared with the attending physicians’ coding.
Although this may be true and considering that the
attending physicians are foot and ankle surgeons who have
more experience in coding, it probably is true, but the
authors provide no evidence that it is true and they do not
have a means of knowing if the attending physicians’
comfort with coding is well founded. The discordance
could easily be statistically significant but clinically irrele-
vant, but that is not the reason I felt the need to write this
commentary. I believe the authors missed an opportunity to
make an important conclusion about resident education.
Coding is difficult and most of the time correct coding
seems more of an art than a science. It certainly takes
training and practice. The evidence for this is my personal
experience, the number of well-attended coding courses,
and the number of practices and hospitals that hire
professional coders so that they can decrease the risk of
Correspondence: Inquiries to Dempsey Springfield, Orthopaedic Surgery, Partners Health-
care, 55 Fruit Street, Bullfinch 2, Boston, MA 02114; e-mail: dspringfield@partners.org
186 Journal of Surgical Education  & 2014 Association of Program Directors in Surgery. Published by
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being accused of coding violations. The significant conclu-
sions from this study should not be that the attending
physicians are more accurate with coding and more com-
fortable with their coding than the residents. The significant
conclusion is that this residency program should take more
seriously the need to educate residents how to code.
Although the authors do not have the data to generalize
this conclusion, I suspect it applies to many, if not most,
residency programs.
Coding education requires didactic instruction, practice,
assessment, and feedback. Attending physicians should
teach coding, have residents’ code cases, and then review
the residents’ coding. Periodically, both attending physi-
cians’ and residents’ codes should be reviewed by a
professional coder for accuracy. The authors should con-
clude that their residency program has let the residents
down by not providing them with sufficient coding
education and although it is always safe to recommend
more research in an area, their final sentence should be not
that additional training may be beneficial, but that addi-
tional training will be beneficial. Because there is minimal
literature of this type, I suspect that few programs have
evaluated the results of their teaching of coding, so another
conclusion should be that, at a minimum, residency
programs should evaluate the ability of their residents to
properly code their procedures.
There is a shift in emphasis occurring in graduate medical
education. Not too long ago, residency programs were
required only to teach medical knowledge and technical
skills. It was assumed that professionalism, communication
skills, the ability to evaluate the quality of one’s practice, and
to work within teams did not need to be taught. Some of us
believe that many of the problems in healthcare delivery in
the United States resulted from physicians not being taught
these skills. The public, through the Accreditation Council
for Graduate Medical Education, has challenged educators of
physicians-in-training to instill these skills during residency.
Professionalism demands proper coding. Residency programs
need to take this assignment seriously.
Dempsey Springfield, MD
Orthopaedic Surgery, Partners Healthcare, Boston,
Massachusetts
E-mail address: dspringfield@partners.org
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