Increasing Billing Accuracy of Initial Inpatient Visits in a Multispecialty Academic Hospital Group Using Pdsa Methodology

Background:

The financial success of a hospital medicine practice is dependent on accurate billing and documentation practices. Academic hospitalists face the additional challenge of educating resident physicians on appropriate documentation. As most patients admitted to a tertiary care center are medically complex, initial inpatient E/M code 99221 often signifies a deficiency in documentation rather than low medical complexity. In a retrospective review of billing data for our hospital medicine group, we found that 15% of initial inpatient visits were billed as 99221 codes, compared to the national average of 4.7% for university-based teaching hospitals.

Purpose:

We sought to improve the accuracy of initial inpatient E/M coding in a hospital medicine multi-specialty group through the use of PDSA (Plan-do-study-act) QI methodology. 

Description:

A multi-specialty team comprised of neurologists and internal medicine hospitalists was formed to perform chart abstractions, determine root causes, and develop interventions. The primary goal was to reduce average percentage of 99221 coding to less than 5%.

Coder mistakes and provider documentation errors were determined to be the largest contributing factors. PDSA cycle 1 targeted coders with re-education on attestations and retrospective correction of incorrect charges. PDSA cycle 2 was aimed at providers. An interactive 30-minute education session was presented to the hospital medicine group, during which providers filled out a cause-and-effect diagram to better understand contributors to documentation omissions.  Documentation “Do’s and Don’ts” tip sheets were emailed to all group members following the session.  PDSA cycle 3 targeted resident physicians.  A billing mini-curriculum was created and presented to residents during noon conference. All data was presented to our hospital medicine group during monthly business meetings to engage providers and ensure transparency.

Our efforts saw a reduction in the average percentage of 99221 coding from 15% to 5% during the first 5 months of our intervention. We conservatively estimate that with this decrease we will have avoided a loss of $200,000 for services performed due to inadequate documentation.

Conclusions:

The use of PDSA QI methodology can be an effective mechanism for improving accurate and appropriate documentation while encouraging culture change and team building in a multi-specialty hospitalist group with different documentation requirements. Tracking the percentage of 99221 codes billed can be an informative group indicator for billing system issues and documentation accuracy, particularly when used in a university-based practice.