Lost in translation: Focused documentation improvement benefits trauma surgeons

Fox, Nicole; Swierczynski, Patricia; Willcutt, Rebecca; Elberfeld, Adrienne; Mazzarelli, Anthony

doi:10.1016/j.injury.2016.04.035

Cited by 12 publications

(14 citation statements)

References 7 publications

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“…Although numerous prior studies have shown similar outcomes for surgical specialties, in particular, this study focused on disease-specific documentation within the PED, which is an area of medical care in which rapid but thorough documentation is particularly key for optimized billing, given high patient throughput, volume, and acuity. [1][2][3][6][7][8] An external audit of all PED encounters showed 81% agreement between external coding and assigned CPT codes. During that same period, the baseline rate of billing agreement among asthma patients was only 71%.…”

Section: Discussionmentioning

confidence: 99%

Implementation of a Provider’s Asthma-specific Note to Optimize Billing in the Pediatric Emergency Department

Hegamyer

Zomorrodi

Nelson

2022

Pediatric Quality &Amp; Safety

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Introduction: There is broad variability in provider documentation for asthma encounters within the pediatric emergency department. Inadequate provider documentation leads to discrepancies between the ideal current procedural terminology (CPT) code and the assigned CPT code based on the care provided. Multiple studies demonstrate improvement in medical provider documentation after implementing standardized documentation templates and educational programs. The primary aim of this project was to improve the concordance between the ideal CPT code and assigned CPT code from a baseline of 71% to 85% in 12 months. Methods: We introduced an asthma-specific note template in January 2018. We reviewed a random sample of 20 encounters per month to compare the ideal and assigned CPT codes in the baseline and intervention periods. The primary outcome measure was the percentage of encounters with agreement between ideal and assigned billing. The secondary outcome measure was the percentage of encounters with intravenous magnesium that were billed for critical care. The process measure was asthma note usage. Provider education and Plan-Do-Study-Act (PDSA) cycles continued throughout the intervention period. We used statistical process control to measure changes over time. Results: We reviewed 740 patient encounters over a 12-month baseline and 25-month intervention period. The average agreement between ideal and assigned CPT code increased from 71% to 89%, with 84% usage of the asthma note template. The percentage of critical care billing for intravenous magnesium increased from 15% to 55%. Conclusion: Implementation of an asthma-specific provider note template in the pediatric emergency department improved billing optimization and critical care billing.

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Section: Discussionmentioning

confidence: 99%

Implementation of a Provider’s Asthma-specific Note to Optimize Billing in the Pediatric Emergency Department

Hegamyer

Zomorrodi

Nelson

2022

Pediatric Quality &Amp; Safety

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“…7 At Cooper University Hospital in New Jersey, a CDI program for the trauma service resulted in CMI increase from 1.80 to 2.11. 8 The critical feature of this program was a coding specialist who concurrently sent CDI queries to the trauma surgeons. We aimed to make the appropriate documentation easier for surgeons to achieve, on the front end, note writing with the intention of decreasing the volume of subsequent CDI queries sent by coding analysts.…”

Section: Discussionmentioning

confidence: 99%

Back to the Future: Impact of a Paper-Based Admission H&P on Clinical Documentation Improvement at a Level 1 Trauma Center

Weinberg

Chapple

Gagliano

et al. 2019

The American Surgeon

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The Medicare Severity Diagnosis Related Group (MS-DRG) weight, as derived from the MS-DRG assigned at discharge, is in part determined by the physician-documented diagnoses. However, the terminology associated with MS-DRG determination is often not aligned with typical physician language, leading to inaccurate coding and decreased hospital reimbursements. The goal of this study was to evaluate the impact of a diagnosis picklist within a paper-based history and physical examination (H&P) on the average MS-DRG weight and the Case-mix index (CMI). Our trauma center implemented a paper H&P form for trauma patients featuring picklist diagnoses aligned with the MS-DRG terminology and arranged by the physiologic system. To evaluate its impact, we conducted a cohort study using data from our trauma registry between July 2015 and November 2017. Our cohort included 442 (26.0%) paper and 1,261 (74.0%) dictated H&Ps. Average CMI (2.56 vs 2.15) and expected patients ($25,057 vs $19,825) were higher for the paper group ( P < 0.001, P = 0.002). Adjusted regression models demonstrated paper coding to be associated with 0.265 CMI points, translating to an average increase in expected payment of 6.5 per cent per patient. Utilization of a standardized, paper-based H&P template with picklist diagnoses was associated with a higher trauma service CMI and higher expected payments. Preprinted diagnoses that align with the MS-DRG terminology lead to clinical documentation improvement.

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“…Other improvement projects focused on intensive documentation education and concurrent auditing for trauma and critical care physicians. 20,21 While these projects successfully achieved their improvement goals, they required expensive and time-consuming educational sessions and retrospective team auditing. We were able to perform a focused intervention utilizing a novel technology to augment usual coding education and practices.…”

Section: Summary and Interpretationmentioning

confidence: 99%

Improving Documentation Using a Real-Time Location System in a Pediatric Emergency Department

2021

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Background Appropriate documentation of critical care services, including key time-based parameters, is critical to accurate severity of illness metrics and proper reimbursement. Documentation of time-based elements for critical care services performed in emergency departments (ED) remains inconsistent. We integrated electronic medical record and real-time location system (RTLS)-derived data to augment quality improvement methodology. Objective We aimed to increase the proportion of patient encounters with critical care services performed at a pediatric ED that had appropriate documentation from a baseline of 76 to 90% within 6 weeks. Methods The team formulated a framework of improvement and performed multiple plan-do-study-act cycles focused on key drivers. We integrated the capabilities of an RTLS for precise location tracking to identify patient encounters in which critical care services were performed and to minimize unnecessary audits and feedback. We developed an intervention using iterative revisions to address key drivers and improve documentation. The primary outcome was the proportion of patient encounters for which critical care services were performed for which a time-based attestation was documented in the medical record. Results We analyzed 92 encounters between March 2020 and April 2020. While the proportion of eligible patient encounters with critical care documentation improved from 76 to 85%, this change was unable to be directly attributed to improvement efforts. Patients with respiratory complaints encompassed the majority of eligible encounters without appropriate documentation. Conclusion Utilizing improvement methodology and a novel application of RTLS, we successfully identified the co-location of physicians with patients receiving critical care services and designed interventions to improve documentation of critical care services provided in a pediatric ED. While changes were not able to be attributed to improvement efforts in this project, this project demonstrates the utility of RTLS to augment and inform systematic improvement efforts.

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Lost in translation: Focused documentation improvement benefits trauma surgeons

Cited by 12 publications

References 7 publications

Implementation of a Provider’s Asthma-specific Note to Optimize Billing in the Pediatric Emergency Department

Implementation of a Provider’s Asthma-specific Note to Optimize Billing in the Pediatric Emergency Department

Back to the Future: Impact of a Paper-Based Admission H&P on Clinical Documentation Improvement at a Level 1 Trauma Center

Improving Documentation Using a Real-Time Location System in a Pediatric Emergency Department

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