Improving Provider Documentation and Billing Through the Implementation of a Standardized Note

Abstract

Background: As the demand for critical care services grow and the intensivist provider pool diminishes, advanced practice providers are increasingly integrated into intensive care units. However, advanced practice providers often enter the profession without proficiency in the billing practices necessary to ensure their work is reimbursed. Critical Care Management, Current Procedural Terminology codes 99291 and 99291, are services exclusive of any global payment. These two codes represent a significant amount of a provider’s billable activities in the intensive care setting. In the absence of education addressing billing requirements for these codes, provider documentation often fails to meet the standard for reimbursement. Money is left on the table and provider work is not adequately represented in reimbursement. Targeted education and standardized documentation can improve the quality of documentation, billing competency, and contribute to increased revenue. Local Problem: In surveys conducted pre-implementation, the majority of advanced practice providers at the project site reported a lack of billing and requisite documentation training and competency. Additionally, documentation audits validated that, often, advanced practice provider notes did not support their billable activities. The aim of this quality improvement project was to implement and evaluate the effectiveness of a standardized Event Note to improve documentation and billing of critical care management. Interventions: The implementation of this quality improvement project took place over a 12week period. Primary components of the implementation included: pre-implementation survey, pre-implementation online education module, implementation of a standardized Event Note, and post-implementation survey. Data were collected from all primary components. Results: Post-implementation of the standardized Event Note and online education module, 87.2% of providers agreed or strongly agreed with the statement, “The online billing education improved my billing competency.” Additionally, 94.9% agreed or strongly agreed with the statement, “This project heightened my awareness regarding the importance of documenting critical care events.” Further, 116 events notes and 5,777 critical care minutes were documented post-implementation compared with 64 event notes and 2,184 critical care minutes entered in the pre-implementation period. Critical care evaluation and management codes require the reporting of time in minutes. The standardized Event Note includes a prompt to enter the number of minutes spent in exclusive attention to a patient. Twenty-four event notes made no mention of time in the pre-implementation period and only six notes omitted a time element in the postimplementation period. This demonstrates a 75.00% decrease in event notes without a time element. The six event notes without a time element were the result of the provider using free text to document (n=2) or using an older unit-based event note (n=4). Post-implementation, 82.76% of all event notes submitted utilized the vetted, standardized Event Note. Conclusions: Advanced practice provider education and use of the standardized Event Note increased billing competency and awareness related to thorough and timely documentation of critical care management. Engaging providers in targeted education and providing standardized notes, built with attention to communication and required billing elements, is an effective and efficient means of improving documentation and reimbursement.