Background: Hospitalists fulfill a wide range of clinical responsibilities including off-hour cross-coverage that often requires extensive direct patient care. Although accurate documentation of physician services—such as cognitive work, technical skills, and time—forms the foundation for generating relative value units (RVUs), inconsistent documentation practices within our hospitalist group have hindered the appropriate recognition of this high-value work.
Purpose: We aimed to more accurately reflect the value of our cross-coverage work by improving provider documentation that supports RVU generation—specifically through the increased and appropriate use of the Prolonged Services CPT code 99418, which is most commonly associated with cross-cover activities.
Description: In 2023, hospitalists at our tertiary-care academic medical center generated a median of 224 RVUs per month ($507 per provider) using CPT code 99418. In January 2024, we introduced an educational initiative to optimize documentation of cross-cover events, which included training on appropriate use of the prolonged services CPT code 99418 and the rollout of a new electronic medical record (EMR) smart phrase. This education was delivered through division-wide meetings and email communication over 2 months. Between January and September 2024, the median monthly RVUs associated with CPT code 99418 increased to 515 per month ($1,331 per provider). However, use of the smart phrase remained limited because hospitalists needed to remember the phrase and manually insert it into a blank note template.In October 2024, we implemented a streamlined, standardized cross-cover note template within the EMR. The template was designed to be easily accessible, adaptable to a range of clinical scenarios, and embedded with documentation prompts and billing instructions when required criteria were met. Over the subsequent 11 months (October 2024–August 2025), hospitalists used the template 2,321 times (an average of 211 uses per month), and median monthly RVUs from CPT code 99418 increased further to 654 per month ($1,657 per provider). Use of the template remained consistently high throughout this period (Figure).
Conclusions: Our intervention not only improved the visibility of cross-cover work but also produced a substantial increase in RVUs generated from CPT code 99418. Although the gains observed in early 2024 were largely attributable to provider education on appropriate billing practices—which encompasses activities beyond cross-cover tasks—the implementation of the standardized cross-cover note template yielded additional and sustained improvement. This suggests that the template enabled the hospital to more reliably capture this work in the form of RVUs. In line with the Institute for Healthcare Improvement’s Action Hierarchy Tool(1), interventions that minimized reliance on provider memory were more effective and produced more durable change than those requiring individuals to remember and execute steps.
