Search

Objectives: To improve access, the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018 mandated a 2-year study of medical scribes in Veterans Health Administration specialty clinics and emergency departments. Medical scribes are employed in clinical settings with the goals of increasing provider productivity and satisfaction by minimizing physicians' documentation burden. Our objective is to quantify the economic outcomes of the MISSION Act scribes trial., Methods: A cluster-randomized trial was designed with 12 Department of Veterans Affairs (VA) medical centers randomized into the intervention. We estimated the total cost of the trial, cost per scribe-year, and projected cost of hiring additional physicians to achieve the observed scribe productivity benefits in relative value units and visits per full-time-equivalent over the 2-year intervention period (June 30, 2020 to July 1, 2022)., Results: The estimated cost of the trial was $4.6 million, below the Congressional Budget Office estimate of $5 million. A full-time scribe-year cost approximately $74 600 through contracting and $62 900 through VA hiring. Randomization into the trial led to an approximate 30% increase in productivity in cardiology and 20% in orthopedics. The projected incremental cost of using additional physicians instead of scribes to achieve the same productivity benefits was nearly $1.7 million more, or 75% higher, than the observed cost of scribes in cardiology and orthopedics., Conclusions: As the largest randomized trial of scribes to date, the MISSION Act scribes trial provides important evidence on the costs and benefits of scribes. Improving productivity enhances access and scribes may give VA a new tool to improve productivity in specialty care at a lower cost than hiring additional providers., Competing Interests: Author Disclosures Author disclosure forms can be accessed below in the Supplemental Material section., (Copyright © 2024. Published by Elsevier Inc.)

Objective: Accurate documentation of patient care and acuity is essential to determine appropriate reimbursement as well as accuracy of key publicly reported quality metrics. We sought to investigate the impact of standardized note templates by inpatient advanced practice providers (APPs) on evaluation and management (E/M) charge capture, including outside of the global surgical package (GSP), and quality metrics including case mix index (CMI) and mortality index (MI). We hypothesized this clinical documentation initiative as well as improved coding of E/M services would result in increased reimbursement and quality metrics., Methods: A documentation and coding initiative on the heart and vascular service line was initiated in 2016 with focus on improving inpatient E/M capture by APPs outside the GSP. Comprehensive training sessions and standardized documentation templates were created and implemented in the electronic medical record. Subsequent hospital care E/M (current procedural terminology codes 99231, 99232, 99233) from the years 2015 to 2017 were audited and analyzed for charge capture rates, collections, work relative value units (wRVUs), and billing complexity. Data were compared over time by standardizing CMS values and reimbursement rates. In addition, overall CMI and MI were calculated each year., Results: One year following the documentation initiative, E/M charges on the vascular surgery service line increased by 78.5% with a corresponding increase in APP charges from 0.4% of billable E/M services to 70.4% when compared with pre-initiative data. The charge capture of E/M services among all inpatients rose from 21.4% to 37.9%. Additionally, reimbursement from CMS increased by 65% as total work relative value units generated from E/M services rose by 78.4% (797 to 1422). The MI decreased over the study period by 25.4%. Additionally, there was a corresponding 5.6% increase in the cohort CMI. Distribution of E/M encounter charges did not vary significantly. Meanwhile, the prevalence of 14 clinical comorbidities in our cohort as well as length of stay (P = .88) remained non-statistically different throughout the study period., Conclusions: Accurate clinical documentation of E/M care and ultimately inpatient acuity is critical in determining quality metrics that serve as important measures of overall hospital quality for CMS value-based payments and rankings. A system-based documentation initiative and expanded role of inpatient APPs on vascular surgery teams significantly improved charge capture and reimbursement outside the GSP as well as CMI and MI in a consistently complex patient population., (Published by Elsevier Inc.)

Employing medical scribes can boost revenue for a practice, the authors show, well beyond being an opportunity to expand patient volume.

Postoperative complications (PC) are a basic health outcome, but no surgery service in the world records and/or audits the PC associated with all the surgical procedures it performs. Most studies that have assessed the cost of PC suffer from poor quality and a lack of transparency and consistency. The payment system in place often rewards the volume of services provided rather than the quality of patients' clinical outcomes. Without a thorough registration of PC, the economic costs involved cannot be determined. An accurate, reliable appraisal would help identify areas for investment in order to reduce the incidence of PC, improve surgical results, and bring down the economic costs. This article describes how to quantify and classify PC using the Clavien-Dindo classification and the comprehensive complication index, discusses the perspectives from which economic evaluations are performed and the minimum postoperative follow-up established, and makes various recommendations. The availability of accurate and impartially audited data on PC will help reduce their incidence and bring down costs. Patients, the health authorities, and society as a whole are sure to benefit., Competing Interests: Conflict-of-interest statement: The authors have no conflict of interest to declare., (©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.)

Objective: The study sought to review recent literature regarding use of speech recognition (SR) technology for clinical documentation and to understand the impact of SR on document accuracy, provider efficiency, institutional cost, and more., Materials and Methods: We searched 10 scientific and medical literature databases to find articles about clinician use of SR for documentation published between January 1, 1990, and October 15, 2018. We annotated included articles with their research topic(s), medical domain(s), and SR system(s) evaluated and analyzed the results., Results: One hundred twenty-two articles were included. Forty-eight (39.3%) involved the radiology department exclusively and 10 (8.2%) involved emergency medicine; 10 (8.2%) mentioned multiple departments. Forty-eight (39.3%) articles studied productivity; 20 (16.4%) studied the effect of SR on documentation time, with mixed findings. Decreased turnaround time was reported in all 19 (15.6%) studies in which it was evaluated. Twenty-nine (23.8%) studies conducted error analyses, though various evaluation metrics were used. Reported percentage of documents with errors ranged from 4.8% to 71%; reported word error rates ranged from 7.4% to 38.7%. Seven (5.7%) studies assessed documentation-associated costs; 5 reported decreases and 2 reported increases. Many studies (44.3%) used products by Nuance Communications. Other vendors included IBM (9.0%) and Philips (6.6%); 7 (5.7%) used self-developed systems., Conclusion: Despite widespread use of SR for clinical documentation, research on this topic remains largely heterogeneous, often using different evaluation metrics with mixed findings. Further, that SR-assisted documentation has become increasingly common in clinical settings beyond radiology warrants further investigation of its use and effectiveness in these settings., (© The Author(s) 2019. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Purpose: Pressure on physicians to increase productivity is rising in parallel with administrative tasks, regulations, and the use of electronic health records (EHRs). Physician extenders and clinical pathways are already in use to increase productivity and reduce costs and burnout, but other strategies are required. We evaluated whether implementation of medical scribes in an academic urology clinic would affect productivity, revenue, and patient/provider satisfaction., Methods: Six academic urologists were assigned scribes for 1 clinic day per week for 3 months. Likert-type patient and provider surveys were developed to evaluate satisfaction with and without scribes. Matched clinic days in the year prior were used to evaluate changes in productivity and physician/hospital charges and revenue., Results: After using scribes for 3 months, providers reported increased efficiency (p value = 0.03) and work satisfaction (p value = 0.03), while seeing a mean 2.15 more patients per session (+ 0.96 return visits, + 0.99 new patients, and + 0.22 procedures), contributing to an additional 2.6 wRVUs, $542 in physician charges, and $861 in hospital charges per clinic session. At a gross collection rate of 36%, actual combined revenue was + $506/session, representing a 26% increase in overall revenue. At a cost of $77/session, the net financial impact was + $429 per clinic session, resulting in a return-to-investment ratio greater than 6:1, while having no effect on patient satisfaction scores. Additionally, with scribes, clinic encounters were closed a mean 8.9 days earlier., Conclusions: Implementing medical scribes in academic urology practices may be useful in increasing productivity, revenue, and provider satisfaction, while maintaining high patient satisfaction.

Background: The American Academy of Nutrition and Dietetics and the American Society of Parenteral and Enteral Nutrition released a pediatric malnutrition consensus statement in 2014 recommending the use of z-scores as indicators for identification and documentation of malnutrition. A shift in focus is needed on standardizing pediatric malnutrition language at institutions nationwide to make study data comparable. With this standardized language, establishment of institutional baselines for identification, coding, and reimbursement of pediatric malnutrition is crucial to measure process improvements., Objectives: The objectives of this study were to determine the prevalence of malnutrition among pediatric patients at an urban academic medical center, the frequency of malnutrition codes used, and the reimbursement impact of coding for malnutrition., Methods: Electronic medical records of pediatric patients admitted from January 2013 to December 2015 were reviewed. Malnutrition was identified based on registered dietitian identification and z-score. Patients given a malnutrition-related International Classification of Diseases code upon discharge were identified. A reimbursement calculation was performed: the malnutrition-related International Classification of Diseases code was removed to determine the difference in reimbursement with vs without the code., Results: Of the 1,532 admissions included in this study, 464 (30%) were identified as malnourished. A total of 152 (33%) malnourished patients were given a malnutrition-related secondary diagnosis. The calculation revealed that coding for malnutrition resulted in an additional $27,665.70 to the medical center., Conclusion: Malnutrition coding may have a significant financial impact and processes improvement efforts can be made to improve malnutrition coding., (© 2018 American Society for Parenteral and Enteral Nutrition.)

Purpose: To estimate the conditions under which team documentation-having a staff member enter history, place orders, and guide patients-would be financially viable at primary care practices, accounting for implementation costs., Methods: We applied a validated microsimulation model of practice costs, revenues, and time use to data from 643 US primary care practices. We estimated critical threshold values for time saved from routine visits that would need to be redirected to new visits to avoid net revenue losses under: (1) a clerical documentation assistant (CDA) strategy where a scribe assists with recordkeeping; and (2) an advanced team-based care (ATBC) strategy where medical assistants perform history, documentation, counseling, and order entry., Results: Using a fee-for-service model, we estimated that physicians would need to save 3.5 (95% CI, 3.3-3.7) minutes/encounter under a CDA strategy and 7.4 (95% CI, 4.3-10.5) minutes/encounter under an ATBC strategy to prevent net revenue losses. The redirected time would be expected to add 317 visit slots per year under CDA strategy, and 720 under ATBC strategy. Using a capitated payment model, physicians would need to empanel at least 127 (95% CI, 70-187) more patients under CDA and 227 (95% CI, 153-267) under ATBC to prevent revenue losses. Additional patient visits expected would be 279 (95% CI, 140-449) additional visit slots per year under CDA and 499 (95% CI, 454-641) under ATBC., Conclusions: Financial viability of team documentation under fee-for-service payment may require more physician time to be reallocated to patient encounters than under a capitated payment model., (© 2018 Annals of Family Medicine, Inc.)

Background: Advance care planning (ACP) documents patient wishes and increases awareness of palliative care options., Objective: To study the association of outpatient ACP with advanced directive documentation, utilization, and costs of care., Design: This was a case-control study of cases with ACP who died matched 1:1 with controls. We used 12 months of data pre-ACP/prematch and predeath. We compared rates of documentation with logit model regression and conducted a difference-in-difference analysis using generalized linear models for utilization and costs., Setting/subjects: Medicare beneficiaries attributed to a large rural-suburban-small metro multisite accountable care organization from January 2013 to April 2016, with cross reference to ACP facilitator logs to find cases., Measurements: The presence of advance directive forms was verified by chart review. Cost analysis included all utilization and costs billed to Medicare., Results: We matched 325 cases and 325 controls (51.1% female and 48.9% male, mean age 81). 320/325 (98.5%) ACP versus 243/325 (74.8%) of controls had a Healthcare Power of Attorney (odds ratio [OR] 21.6, 95% CI 8.6-54.1) and 172/325(52.9%) ACP versus 145/325 (44.6%) controls had Practitioner Orders for Life Sustaining Treatment (OR 1.40, 95% CI 1.02-1.90) post-ACP/postmatch. Adjusted results showed ACP cases had fewer inpatient admissions (-0.37 admissions, 95% CI -0.66 to -0.08), and inpatient days (-3.66 days, 95% CI -6.23 to -1.09), with no differences in hospice, hospice days, skilled nursing facility use, home health use, 30-day readmissions, or emergency department visits. Adjusted costs were $9,500 lower in the ACP group (95% CI -$16,207 to -$2,793)., Conclusions: ACP increases documentation and was associated with a reduction in overall costs driven primarily by a reduction in inpatient utilization. Our data set was limited by small numbers of minorities and cancer patients.

Background: More than half of the 50 states (27) and the District of Columbia require reporting of Serous Reportable Events (SREs). The goal is to hold providers accountable and improve patient safety, but there is little information about the administrative cost of this reporting requirement. This study was conducted to identify costs associated with investigating and reporting SREs., Methods: This qualitative study used case study methods that included interviewing staff and review of data and documents to investigate each SRE occurring at one academic medical center during fiscal year 2013. A framework of tasks and a model to categorize costs was created. Time was summarized and costs were estimated for each SRE., Results: The administrative cost to process 44 SREs was estimated at $353,291, an average cost of $8,029 per SRE, ranging $6,653 for an environmental-related SRE to $21,276 for a device-related SRE. Care management SREs occurred most frequently, costing an average $7,201 per SRE. Surgical SREs, the most expensive on average, cost $9,123 per SRE. Investigation of events accounted for 64.5% of total cost; public reporting, 17.2%; internal reporting, 10.2%; finance and administration, 6.0%; and 2.1%, other. Even with 26 states mandating reporting, the 17.2% incremental cost of public reporting is substantial., Conclusion: Policy makers should consider the opportunity costs of these resources, averaging $8,029 per SRE, when mandating reporting. The benefits of public reporting should be collectively reviewed to ensure that the incremental costs in this resource-constrained environment continue to improve patient safety and that trade-offs are acknowledged., (Copyright © 2017 The Joint Commission. Published by Elsevier Inc. All rights reserved.)

Background: Electronic health records (EHRs), despite their positive attributes, increase physician workload and decrease efficiency. The aim of this study was to evaluate the impact of scribes in the Inflammatory Bowel Disease Clinic on improvement of the physician-patient relationship, physician productivity, clinical efficiency, and achievement of some Physician Quality Reporting System (PQRS) metrics., Methods: We analyzed of pre- and postscribe data between fiscal years 2015 (FY15) and 2016 (FY16) using data from patients at the Inflammatory Bowel Clinic at the University of Florida. The main outcomes were patient satisfaction scores (PSS), qualitative physician interview, clinic appointment lengths, work relative value units (wRVUs), level of coding, revenue, and PQRS data on bone density screening and vaccination., Results: PSS increased from 6.8/10 to 9.2/10 (P < 0.01), clinic appointment length decreased by 13.5 minutes (P < 0.05), and documentation stress decreased. Clinic visits increased by 76, leading to an increase in work RVUs by 332.55, total charges billed by $71,439, and total charges collected by $27,387 between the first quarters of FY15 and FY16. The extra revenue for the first quarter was 536% higher than the salary of the scribe for the same period ($4302.84). There was a 1.8-fold increase in referrals for bone density scans and 2.9-fold and 4.8-fold increases in vaccination rates for influenza and pneumonia, respectively., Conclusions: The use of scribes improved the physician-patient relationship, clinical efficiency, physician productivity, bone density screening, and vaccinations for flu and pneumonia. If adopted by health systems, it may lead to significant cost savings and improved clinical outcomes.

With the advent of the electronic medical record, the documentation burden of the trauma surgeon has become overwhelming. To help, our trauma division added scribes to the rounding team. We hypothesized that scribe utilization would improve our documentation efficiency and offer a financial benefit to the institution. A review of trauma surgeon documentation and billing was performed at a Level I trauma center over two time periods: January to May 2014 (no scribes) and January to May 2015 (scribes). The number of notes written by trauma surgeons was obtained, as were documentation charges. Documentation efficiency was determined by noting both the hour of the day in which inpatient progress notes were written and the number of notes written after patient discharge. In the 2014 period, a total of 9726 notes were written by trauma attendings. In the 2015 period, 10,933 were written. Despite having 407 fewer trauma patient-days in the 2015 period, the group wrote 343 notes/week versus 298 notes/week (P = 0.008). More inpatient progress notes were written earlier in the working day and fewer were written in the evening. Fewer notes were written after patient discharge (12.7 vs 8.4%). A total of 1,664 hours of scribe time were used over the 5-month period, generating an expense of $32,787. The additional notes generated by scribes resulted in $191,394 in charges. Conservatively, assuming a 20 per cent charge reimbursement, the cost of the scribes was covered. The addition of scribes to the daily trauma rounding team improved note efficiency and increased charge capture at our center.

Objectives: To evaluate the impact that an innovative automated ultrasound (US) work flow, which allows for bedside performance of examination documentation and order placement, has on point-of-care US billing compared to ordering US examinations through an electronic medical record., Methods: We conducted a retrospective review of point-of-care US billing data (March 2014-February 2016) for adult and pediatric emergency departments with an emergency medicine residency and a US fellowship. An innovative work flow with the ability to automate US billing and selectively transfer the images and reports for patient care examinations to an electronic medical record and picture archiving and communication system using the QPath US work flow solution (Telexy Healthcare, Maple Ridge, British Columbia, Canada) was implemented. The total number of examinations billed and percent increase in technical and professional revenue, excluding examinations performed by US fellows, before and after implementation of the automated work flow innovation were determined., Results: After implementation of our automated US work flow process, the number of patient care US examinations billed increased significantly due to completing documentation and immediate billing determination at the bedside. The increase in percent billing relative to total examinations was noted in both technical (32% to 61%; P < .0001) and professional (37% to 65%; P < .0001) billing components. In addition, there was a net increase in technical and professional fee revenue to 96% and 78%, respectively., Conclusions: The implementation of an innovative automated work flow to include bedside point-of-care US documentation, order placement, and the automated transfer of images and reports led to a significant increase in US billing revenue, documentation, and compliance., (© 2017 by the American Institute of Ultrasound in Medicine.)

Accurate and reliable medical records are necessary for assessing, improving, and reimbursing healthcare services. Clear and concise physician documentation is essential to assuring accurate and reliable medical records. Yet, prior literature reveals surgery residents do not receive adequate, beneficial education on medical record documentation and coding. This is concerning because the evaluation of and reimbursement for healthcare service delivery relies on the physician's ability to produce appropriate medical records, which then get translated into billable codes. This pilot study suggests hospitals may incur significant financial loss in revenue due to inaccurate clinical documentation by residents. Thus, educational training for medical residents in the area of clinical documentation and hospital-specific coding practices may prove financially advantageous.

Background: Scribe use throughout health care is becoming more common. There is limited peer-reviewed literature supporting this emerging role in health care despite rapid uptake of the role., Objectives: Our study assesses impact of scribes on relative value units (RVUs) in adult and pediatric emergency departments (EDs)., Methods: A prospective cohort study was developed in a tertiary academic ED. Charts were coded by an external billing and coding company, then returned and mapped by International Classification of Diseases, 9th revision diagnostic codes. After training by a staff member with significant experience in implementing scribe programs, scribes provided 1-to-1 support to a provider as staffing allowed. Comparisons were made between scribed and nonscribed visits., Results: There were 49,389 patient visits during the study period (39,926 adult [80.84%] and 9463 pediatric [19.16%] visits), of which 7865 (15.9%) were scribed. For adults, scribed visits produced 0.20 additional RVUs per patient (p < 0.001). Scribes generated additional RVUs in Emergency Severity Index (ESI) 2 (p < 0.001) and 3 (p < 0.001) patients. There were variable effects of scribes on RVUs by diagnostic codes. For pediatric patients, scribed encounters generated 0.08 fewer RVUs per patient (p = 0.007). ESI score had no effect on RVUs. The impact of scribes on pediatric diagnostic groupings was inconsistent., Conclusions: Scribes had a positive impact on RVUs in adult but not pediatric patients. Among adults, scribes led to higher RVUs in ESI 2 and 3 but not 4 and 5 patients, perhaps suggesting a limitation to improve revenue capture on lower-acuity patients., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose of Study: Avoidable Days/Delays (ADs) account for a large portion of dollars lost for many health care organizations, and with ongoing changes in health care reimbursement, available funds will become increasingly limited. Avoidable Days cannot be reduced or eliminated without accurate causal documentation. The purpose of this study was to determine whether a system upgrade with a change in documentation layout for AD tracking increased case manager compliance with AD documentation. In addition, staff perceptions and opinions on AD documentation were obtained to determine whether or not these perceptions could affect accurate documentation of ADs., Primary Practice Setting: A large academic medical center., Methodology and Sample: Quantitative data were gathered through a survey completed by the hospital's case managers, and raw data were obtained from the electronic health record system on the number of documented ADs before and after the system upgrade., Results: The results indicated that the system upgrade did improve case manager documentation of ADs. Survey results suggested that more education was needed on ADs, including information on financial impact, importance of accurate documentation, and plans for performance improvement initiatives for frequently documented AD causes., Implications for Case Management Practice: The majority of surveyed case managers felt that they would benefit from increased education on AD documentation. Recommendations for case management practice include (1) incorporating AD education into the orientation curriculum for new case managers, (2) readdressing the importance of AD documentation in case managers' annual review education, and (3) extending AD education to additional hospital staff to make AD tracking an organizational commitment.

Background: Vascular surgery procedural reimbursement depends on accurate procedural coding and documentation. Despite the critical importance of correct coding, there has been a paucity of research focused on the effect of direct physician involvement. We hypothesize that direct physician involvement in procedural coding will lead to improved coding accuracy, increased work relative value unit (wRVU) assignment, and increased physician reimbursement., Methods: This prospective observational cohort study evaluated procedural coding accuracy of fistulograms at an academic medical institution (January-June 2014). All fistulograms were coded by institutional coders (traditional coding) and by a single vascular surgeon whose codes were verified by two institution coders (multidisciplinary coding). The coding methods were compared, and differences were translated into revenue and wRVUs using the Medicare Physician Fee Schedule. Comparison between traditional and multidisciplinary coding was performed for three discrete study periods: baseline (period 1), after a coding education session for physicians and coders (period 2), and after a coding education session with implementation of an operative dictation template (period 3). The accuracy of surgeon operative dictations during each study period was also assessed. An external validation at a second academic institution was performed during period 1 to assess and compare coding accuracy., Results: During period 1, traditional coding resulted in a 4.4% (P = .004) loss in reimbursement and a 5.4% (P = .01) loss in wRVUs compared with multidisciplinary coding. During period 2, no significant difference was found between traditional and multidisciplinary coding in reimbursement (1.3% loss; P = .24) or wRVUs (1.8% loss; P = .20). During period 3, traditional coding yielded a higher overall reimbursement (1.3% gain; P = .26) than multidisciplinary coding. This increase, however, was due to errors by institution coders, with six inappropriately used codes resulting in a higher overall reimbursement that was subsequently corrected. Assessment of physician documentation showed improvement, with decreased documentation errors at each period (11% vs 3.1% vs 0.6%; P = .02). Overall, between period 1 and period 3, multidisciplinary coding resulted in a significant increase in additional reimbursement ($17.63 per procedure; P = .004) and wRVUs (0.50 per procedure; P = .01). External validation at a second academic institution was performed to assess coding accuracy during period 1. Similar to institution 1, traditional coding revealed an 11% loss in reimbursement ($13,178 vs $14,630; P = .007) and a 12% loss in wRVU (293 vs 329; P = .01) compared with multidisciplinary coding., Conclusions: Physician involvement in the coding of endovascular procedures leads to improved procedural coding accuracy, increased wRVU assignments, and increased physician reimbursement., (Copyright © 2016 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Tumour documentation is essential for quality assurance of oncological therapies and as a source of reliable information about the in- and outpatient care. The documentation effort and the associated resource consumption were analysed for the example of breast cancer., Material and Methods: The different steps in the care of patients with primary breast cancer in a standardised disease situation were defined from initial diagnosis to the end of the follow-up. After the pilot phase, a multicentre validation (n=7 centres) was performed with the support of the Federal Ministry of Health. The documentation time points were horizontally collected and analysed with regard to amount, duration and personnel expenses., Results: 57% of the documentation costs are caused by the physicians. Regarding the different centres, documentation costs were calculated between € 352.82 and € 1 084.08 per patient from diagnosis to completion of aftercare. Non-certified centres had a reduced documentation effort and thus lower costs., Conclusions: The results demonstrate the need for a reduction of the documentation effort - particularly for physicians - the most expensive profession in the health system. A quality improvement is expected from the certification with its special requirements. In this context, there is a justified demand for an adequate remuneration of the documentation effort for certified centres. Furthermore, it is necessary to reduce the number of variables for quality assurance and to define them centrally. A comprehensive multi-disciplinary documentation should be achieved. Investments in a single data set and interface enhancements of existing documentation systems should be realised., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Implementation of the electronic medical record (EMR) has introduced several unintended consequences, including increased documentation demands. The purpose of this study was to define the EMR documentation burden and its economic impact at a busy regional Level I trauma center, comparing attending trauma surgeons (TSs) with orthopedic surgeons (OSs), and neurosurgeons (NSs)., Methods: The EMR was queried to determine the number of attending documentation entries during 2014 for TS, OS, and NS. The eight TSs were then surveyed to estimate the time it took to write each note type, and this was used to calculate the total time needed for documentation. The hospital financial database was queried for 2014 hospital charges and work relative value units (WRVUs) for TSs, OSs, and NSs to generate a comparison. The charges and WRVUs were broken down into those generated from nonprocedural documentation and procedures., Results: During 2014, there were 5,864 trauma activations with 3,111 patient admissions. The attending TSs wrote a total of 26,455 documentation entries. Of these notes, 92% were from inpatients, and 74% were progress notes. Documentation time estimates for TSs demonstrated that it took 1,760.5 hours or 73.3 twenty-four-hour days to complete these 26,455 notes. Financial data revealed that 44% of the TS charges were directly related to nonprocedural documentation, compared with 14% for OSs and 7% for NSs. Evaluation of WRVUs demonstrated that 55% of the TS WRVUs were directly related to nonprocedural documentation, compared with 28% for OSs and 19% for NSs., Conclusion: The EMR has introduced a significant documentation burden to the busy TSs. This documentation burden is critical for defining hospital charges and WRVUs, and it differs from that of OSs and NSs. Workflow changes, such as the introduction of scribes, may lessen the documentation burden and improve hospital charges and WRVUs of the TSs.

Objective: identify the average direct cost (ADC) of the activities performed by nursing professionals in the nursing process development and documentation at the medical clinic of a teaching hospital., Method: 1040 activities were observed and the ADC was calculated by multiplying the time spent by professionals by the unit cost of direct labor., Results: the ADC of patient admission was R$ 55.57 (SD=19.44); among the activities of patient follow-up, the assessment phase documentation had the most significant ADC (R$ 17.70 - SD=14.60); the ADC of descriptive records corresponded to R$ 1.21 (SD=1.21) and the ADC of the nursing team for shift change was R$ 54.23 (SD=28.95)., Conclusion: the study promotes visibility of the work performed by nursing professionals in the development of the nursing process, providing financial data to ensure consistent arguments for proper resources to its feasibility.

The objective of residency training is to produce physicians who can function independently within their chosen subspecialty and practice environment. Skills in the business of medicine, such as clinical billing, are widely applicable in academic and private practices but are not commonly addressed during formal medical education. Residency and fellowship training include limited exposure to medical billing, but our academic department's performance of these skills was inadequate: in 56% of trainee-generated outpatient notes, documentation was insufficient to sustain the chosen billing level. We developed a curriculum to improve the accuracy of documentation and coding and introduced practice changes to address our largest sources of error. In parallel, we developed tools that increased the speed and efficiency of documentation. Over 15 months, we progressively eliminated note devaluation, increased the mean level billed by trainees to nearly match that of attending physicians, and increased outpatient revenue by $34,313/trainee/year. Our experience suggests that inclusion of billing education topics into the formal medical curriculum benefits both academic medical centers and trainees., (© 2014 American Academy of Neurology.)

As a part of the health care reform 2007 the German risk structure compensation scheme was extended so as to connect the financial cash flow towards the payers to morbidity information from ambulatory care. Within this context, morbidity information consists of prescriptions as well as coded ambulatory diagnoses. Accordingly, a high quality of coding is essential for a morbidity compatible allocation of funds. The aim of this study was to evaluate coding quality via qualifying characters as well as to identify future challenges. It focuses on diagnoses which are qualified as "assured" or "post-treatment" from about 350 million diagnoses of about 11 k practitioners' treatment of 2.7 million AOK PLUS insurants in Saxony and Thuringia during the years 2007-2010. The practitioners' documented diagnoses were aggregated within several groups according to the code of specialisation which is attached to the practitioner's 9-digit lifelong identification number (LANR). As a result, the number of "assured" diagnoses generally rose from year to year. Furthermore, diagnoses marked as "assumption" or "exclusion" remain constant over time. We identified a lack of diagnosis coding precision regarding the condition after certain medical events. In particular, general practitioners tend to use diagnosis codes qualified as "post-treatment" instead of using correct "assured" diagnoses qualified for conditions after certain events. Consequently, we expect adverse effects evaluating the cost of diseases as only "assured" diagnoses are considered within the risk transfer compensation scheme., (© Georg Thieme Verlag KG Stuttgart · New York.)

If discharge documentation isn't complete and accurate, coders may not use the correct discharge status code, which could affect a hospital's reimbursement. Discharge status codes identify where patients go after discharge. If patients go to some settings before the geometric mean length of stay, a hospital may receive reduced reimbursement. The Centers for Medicare & Medicaid Services has also issued a new set of discharge status codes that indicate scheduled readmissions.

Background and Objectives: The study's aim was to ascertain family physicians' suggestions on how to improve the commonly used US evaluation and management (E/M) rules for primary care., Methods: A companion paper published in Family Medicine's May 2014 journal describes our study methods (Fam Med 2014;46(5):378-84)., Results: Study subjects supported preserving the overall SOAP note structure. They especially suggested eliminating bullet counting in the E/M rules. For payment reform, respondents stated that brief or simple work should be paid less than long or complex work, and that family physicians should be paid for important tasks they currently are not, such as spending extra time with patients, phone and email clinical encounters, and extra paperwork. Subjects wanted shared savings when their decisions and actions created system efficiencies and savings. Some supported recent payment reforms such as monthly retainer fees and pay-for-performance bonuses. Others expressed skepticism about the negative consequences of each. Aligned incentives among all stakeholders was another common theme., Conclusions: Family physicians wanted less burdensome documentation requirements. They wanted to be paid more for complex work and work that does not include traditional face-to-face clinic visits, and they wanted the incentives of other stakeholders in the health care systems to be aligned with their priorities.

Background and Objectives: The study's aim was to deepen our understanding of family physicians' perceptions of the strengths and weaknesses of the widely used US documentation, coding, and billing rules for primary care evaluation and management (E/M) services., Methods: This study used in-depth, qualitative interviews of 32 family physicians in urban and rural, academic, and private practices. Interviews were initiated with a series of grand tour questions asking participants to give examples and personal narratives demonstrating cost efficiencies and cost inefficiencies relating to the E/M rules in their own practices. Investigators independently used an immersion-crystallization approach to analyze transcripts to search for unifying themes and subthemes until consensus among investigators was achieved., Results: The majority of participants reported that the documentation rules, coding rules, and common fees for procedures and preventive services were reasonable. The E/M documentation rules for all other visit types, however, were perceived by the participants as unnecessarily complicated and unclear. The existing codes did not describe the actual work for common clinic visits, which led to documenting and coding by heuristics and patterns. Participants reported inadequate payment for complex patients, multiple patient concerns in a single office visit, services requiring extra time beyond a standard office visit, non-face-to-face time, and others. The E/M rules created unintended negative consequences such as family physicians not accepting Medicare or Medicaid patients, inaccurate documentation, poor-quality care, and system inefficiencies such as unnecessary tests and referrals., Conclusions: Family physicians expressed many problems and frustrations with the existing E/M documentation, coding, and billing rules and felt the system undervalued and unappreciated them for the complex and comprehensive care they provide. Findings of this study could inform improved guidelines for primary care documentation, coding, and billing.

Mountain State Health Alliance opened a free heart failure clinic after determining that patients' inability to get a timely follow-up appointment and financial issues were the cause of many readmissions. The clinic is in a convenient location, across the street from the hospital. The nurse practitioner who runs the program sees many of the patients while they are still in the hospital to inform them about the clinic. Interventions include help signing up for medication assistance, education for patients and family members, and ongoing support.

Background: Facial trauma is among the most frequent consultations encountered by plastic surgeons. Unfortunately, the reimbursement from these consultations can be low, and qualified plastic surgeons may exclude facial trauma from their practice. An audit of our records found insufficient documentation to justify higher evaluation and management (EM) levels of service resulting in lower reimbursement. Utilizing a standardized consultation form can improve documentation resulting in higher billing and EM levels., Methods: A facial trauma consultation form was developed in conjunction with the billing department. Three plastic surgery residents completed 30 consultations without the aid of the consult form followed by 30 consultations with the aid of the form. The EM levels and billing data for each consultation were obtained from the billing department for analysis. The 2 groups were compared using χ2 analysis and t tests to determine statistical significance., Results: Using our standardized consultation form, the mean EM level increased from 2.97 to 3.60 (P = 0.002). In addition, the mean billed amount increased from $391 to $501 per consult (P = 0.051) representing a 28% increase in billing., Conclusions: In our institution, the development and implementation of a facial trauma consultation form has resulted in more complete documentation and a subsequent increase in EM level and billed services.

Recent articles have addressed the characteristics associated with adult malnutrition as published by the Academy of Nutrition and Dietetics (the Academy) and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). This article describes a successful interdisciplinary program developed by the Department of Food and Nutrition at New York-Presbyterian Hospital to maintain and monitor clinical documentation, ensure accurate International Classification of Diseases 9th Edition (ICD-9) coding, and identify subsequent incremental revenue resulting from the early identification, documentation, and treatment of malnutrition in an adult inpatient population. The first step in the process requires registered dietitians to identify patients with malnutrition; then clear and specifically worded diagnostic statements that include the type and severity of malnutrition are documented in the medical record by the physician, nurse practitioner, or physician's assistant. This protocol allows the Heath Information Management/Coding department to accurately assign ICD-9 codes associated with protein-energy malnutrition. Once clinical coding is complete, a final diagnosis related group (DRG) is generated to ensure appropriate hospital reimbursement. Successful interdisciplinary programs such as this can drive optimal care and ensure appropriate reimbursement.

Background: Evidence suggests that copy-pasted components of electronic notes may not reliably reflect the care delivered. Federal agencies have raised concerns that such components may be used to justify inappropriately inflated claims for reimbursement. It is not known whether copied information is used to justify higher evaluation and management (E&M) charges., Methods: This retrospective cohort study aimed to assess the relationship between the level of evaluation and management (E&M) charges and the method of documentation (none, distinct or copied) of lifestyle counseling (diet, exercise and weight loss) for patients with diabetes mellitus. To determine the association, an ordered multinomial logistic regression model that corrected for clustering within individual providers and patients and adjusted for patient and encounter characteristics was utilized. E&M charge level served as the primary outcome variable. Patients were included if they were followed by primary care physicians affiliated with two academic hospitals for a minimum of two years between 01/01/2000 and 12/13/2009., Results: Lifestyle counseling was documented in 65.4% of 155,168 primary care encounters of 16,164 patients. Copied counseling was identified in 12,527 encounters. In multivariable analysis higher E&M charges were associated with older patient age, longer notes, treatment with insulin, medication changes and acute complaints. However, copied lifestyle counseling was associated with a decrease of 70.5% in the odds of higher E&M charge levels when time spent on counseling (required to justify higher charges based on counseling) was recorded (p<0.0001). This finding is opposite to what would have been expected if the impetus for copied documentation of lifestyle counseling was an increase in submitted E&M charges., Conclusion: There is no evidence that copied documentation of lifestyle counseling is used to justify higher evaluation and management charges. Higher charges were generally associated with indicators of complexity of care.