Optimizing Advanced Practitioner Charge Capture in High-Acuity Surgical Intensive Care Units

Abstract

To determine the impact of standardized critical care documentation tools on charge capture by intensive care unit (ICU) advanced practitioners (APs). Design: Prospective charge capture analysis of AP critical care charges (Current Procedural Terminology codes 99291 or 99292). Setting: Neurosurgical, general surgical, and cardiothoracic ICUs in a level I, 800-bed hospital. The AP provider to patient ratio was 1:6, with 24-hour surgical intensivist oversight. Participants: Advanced practice registered nurses and physician assistants in the ICU. Interventions: Standardized templates were developed to simplify documentation and optimize billing of critical care. All APs participated in comprehensive educational sessions on billing compliance and documentation. Main Outcome Measures: Charge capture was collected for 3 years, and comparisons were made between the first quarter before (fiscal year [FY] 2008), during (FY 2009) and after (FY 2010) implementation. The number of ICU patient-days, length of stay, and of beds was collected. Results: During the implementation/education phase (FY 2009), there were no differences in charge capture compared with FY 2008. Each unit demonstrated an increase in charge capture after implementation, and an overall increase of 48% for all 3 ICUs was seen. The number of admissions and length of stay were not statistically different. The total number of ICU beds increased from 42 to 45 during the evaluation period. The salary offset for APs increased from 62% to 80%. Conclusions: Advanced practitioners represent an important component of the critical care services provided to patients in high-acuity surgical ICUs. Standardized critical care documentation and comprehensive education on evaluation and management guidelines significantly increased charge capture.

Nurse Practitioners and Physician Assistants in Acute and Critical Care: A Concise Review of the Literature and Data 2008–2018

“…The impact of APPs on direct patient care management has been assessed with a number of outcome measures including LOS, mortality rates, readmission rates, post hospital discharge disposition, costs of care, time-savings for physicians, rate of infections, and quality of care metrics such as DVT and stress ulcer disease prophylaxis, and patient care metrics such as time on mechanical ventilation (24, 25, 27, 31–36, 40, 45, 48, 53, 55, 60, 62–64, 68–72). These studies demonstrate similar or improved patient care outcomes.…”

Quality and Financial Impact of Adding Nurse Practitioners to Inpatient Care Teams

“…In many practice models, value is quantified in terms of revenue generation and cost-effectiveness of care. [2][3][4][5][6][7][8][9][10][11][12][13][14] The hiring of NP providers, however, also may have a considerable financial impact related to cost avoidance and improved outcomes in a value-based care design.…”

“…[2][3][4][5][6][7][8][9][10][11][12][13][14] Inpatient practices can be quite different from outpatient practice in terms of patient care outcomes and organizational goals. For instance, outcomes targeted toward an outpatient area might be decreased wait times, whereas an outcome valuable for an inpatient area would be decreased length of stay (LOS).…”

Critical Care Documentation for the Dying Trauma Patient: Are We Recognizing Our Own Efforts?

“…Standardized templating has previously been shown to increase critical care charge capture for advanced practice providers in surgical ICUs. 10 We believe that further standardization of ICU-attending attestations would be a feasible and cost-effective intervention to improve documentation.…”

“…Using the 2018 CMS Physician Fee Schedule to estimate potential missed charges using the difference in national payment amounts between critical care code 99 291 and subsequent care code 99 233 (approximately $120) would indicate that potential missed charges for our institution for these patients totaled in excess of $14 000 over the course of 3 years. 10 In terms of work RVUs, 297.5 RVUs would be missed for these patients if subsequent care codes were used instead of critical care codes. Using data presented in Prin et al including the 1.03 million estimated annual ICU admissions after trauma in the United States, 1 the 10.7% mortality rate in that cohort, the percentage of patients in that study whose ICU length of stay was 2 days or greater (at least 75% based on presented interquartile ranges), the percentage of screened patients in our study eligible for CCT on day prior to death and day of death (73.5% and 52.5%), the percentage of patients in our study missing CCT on those days (42.9% and 53.3%), and the charge differential between codes 99 291 and 99 233; total missed charges for 2 days for moribund trauma patients in the United States could total in excess of $5.9 million annually.…”