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All otolaryngology residents must maintain an operative log available on the ACGME website. It is critical that the resident enter all cases performed and complete the necessary information.

Though oft overlooked and lightly regarded by many, coding is an important part of your duties as a resident for several reasons.  In addition to the fact that it is required, coding demonstrates acquisition of surgical experience and skill as you proceed through residency.  It gives tangible numbers for the cases you’ve done and documents what you are capable of in the operating room, showing your progression as a surgeon.  This information may also be critical as you begin your first job out of residency and your employer is requesting proof of experience with certain procedures or equipment before granting privileges.  No less important, accurate coding has a significant impact on your residency program and plays a prominent part in the Residency Review Committee for Otolaryngology’s assessment of your program’s ability to give you an adequate surgical education.  Coding helps to dictate whether a program can sustain itself or whether it has need of additional residents.

Resident participation in a case can be coded according to three different roles: resident assistant, resident surgeon, and resident supervisor.  At first glance these roles seem self-explanatory, but upon close examination can be nebulous.  Did you only assist in a parotid if you made every move in the case, but your senior resident or attending made the last spread that exposed the main trunk of the nerve?  Are you a supervisor if you did not do anything but hold retractors and point out cranial nerves while your junior took her time through a neck dissection?  Does it even matter what role you choose to code under? 

Accurate coding of surgeon role is important because it shows the progression of your education as a surgeon.  Good surgeons start as good assistants, and you should properly code the cases you assist in to demonstrate that you have laid the groundwork for your eventual surgical acumen.  Coding a case as resident surgeon before one has assisted in a given procedure makes little sense logically and is a red flag to the RRC during site review.

By way of clarification, the following definitions are drawn from the ACGME’s official guidelines:

  • Resident assistant: Performs < 50% of the operation, or ≥ 50% of the operation but not the key portions of the procedure
  • Resident surgeon: Performs ≥ 50% of the operation with the attending physician or resident supervisor, including the key portions of the procedure
  • Resident supervisor: Instructs/assists a more junior resident during a procedure in which the junior resident performs ≥ 50% of the operation, including the key portions of the procedure; the attending physician acts as an assistant or observer

The most critical cases you code are termed “key indicators”.  These 14 categories of procedures constitute what has been deemed by the ACGME to be “representative of otolaryngology surgical education”.  The key indicators are:

  • Congenital Neck Masses
  • Bronchoscopy
  • Airway—Pediatric and Adult
  • Ethmoidectomy
  • Thyroid/Parathyroidectomy
  • Oral Cavity Resection (Glossectomy)
  • Neck Dissection
  • Parotidectomy
  • Mastoidectomy
  • Stapedectomy/Ossiculoplasty
  • Tympanoplasty
  • Flaps and Grafts
  • Mandible/Midface Fractures
  • Rhinoplasty

Each of the key indicator categories has a host of codes beneath it that will qualify as key indicators, and you should be aware of them.  They can be found in the Appendix of the ACGME guidelines starting on page 10. 

Another area that has been cause for consternation for residents is the concept of unbundling.  Confusingly, residents are often encouraged to unbundle their case codes such that a thyroidectomy with central neck dissection could be coded in two separate categories, one for the thyroid and one for the neck dissection.  Things can be further complicated if both lobes are coded separately, and if a parathyroid is resected and reimplanted -- that’s another code.  All the unbundling has to end the minute you graduate, however.  If you Google the word “unbundle” and drop out the references to telephone and cable companies, you’ll find a litany of lawyers who will inform you that unbundling is considered Medicare/Medicaid fraud under the False Claims Act. The US Government even deputizes ordinary citizens, who can act as qui tam whistleblowers in reporting unbundling and collect up to 30% of whatever penalties are collected in the prosecution of the fraud.

The rules don’t apply in residency, however, which makes sense when considering the goals of bundling and unbundling in each context.  Billers bundle cases to streamline the process of payment as much as possible—if a radial forearm free flap required a skin graft as part of the procedure, it should be considered part of that procedure from a payment perspective.  However, in residency the goal of coding is to demonstrate the acquisition of surgical skills, and the harvest of a split thickness skin graft is a separate surgical skill from the harvest and inset of a radial forearm free flap, so both should be coded separately. 

Nonetheless, it doesn’t take much to envision a slippery slope where each minute portion of a case can be unbundled ad infinitum. Dividing the thyroid during tracheostomy does not constitute thyroidectomy, and flipping the marginal mandibular nerve up with the facial vein during submandicular gland excision cannot be coded as facial nerve transposition. The ACGME has warned against some types of unbundling specifically, including dual coding for each side of a tonsillectomy or set of ear tubes. Additionally, reports exist in the literature demonstrating the inflation of case numbers over the years (Rosenberg and Franzese, 2012).

Cases should be unbundled judiciously to demonstrate the acquisition of surgical skill, not artificially inflate the surgical numbers of a resident or program.  Specific examples like the separate coding of tympanoplasty, mastoidectomy, and ossicular chain reconstruction, even though a single code exists to unify all three procedures, are mentioned in the ACGME guidelines.  Your program director will help establish ethical boundaries for unbundling, and a number of resources exist to help you, such as the Official ACGME guidelines

Whatever your feelings about coding, it is worthwhile to become accustomed to and even proficient at it, as coding will only become more important to you once you’ve moved beyond residency and your reimbursement hinges on accurate documentation. Coding each case you do, either right after the procedure or at the end of the day, will ensure you do not omit any case or part thereof.  As with any thankless or less pleasant task, those who are best at it are those who practice and make it a priority.  Your coding will improve exponentially if you make it a habitual part of your surgical day. Happy coding!