553 - Improving Inpatient Pediatric Hospital Medicine Billing and Coding Practices: A Quality Improvement Study

Publication Number: 553.5141

Hadley M. Brighton, Weill Cornell Medicine, New York, NY, United States; Jimin Lee, Weill Cornell Medicine, New York, NY, United States; Snezana Osorio, Weill Cornell Medicine, New York, NY, United States; Nicole kelly, Weill Cornell Medicine, New York, NY, United States; Kiran Gadani-Patel, Weill Cornell Medicine, New York, NY, United States; Rachel Helm, Weill Cornell Medicine, New York, NY, United States; Maria H. Reyes, weill cornell medical, NY, NY, United States; Erika Abramson, Weill Cornell Medicine, Rye Brook, NY, United States

Background: Accurate coding and billing are essential for accurately reflecting patient care provided and ensuring appropriate physician compensation. Locally, insufficient physician knowledge led to under-billing, with key values below the national average despite the high complexity of the patient population.

Objective: To increase work relative value units (wRVUs) per hospital day for pediatric hospital medicine (PHM) patients by 25% over 12 months.

Design/Methods: This ongoing quality improvement (QI) study began in March 2024 at an academic, tertiary care children’s hospital with 17 pediatric hospitalists. An interprofessional team of pediatric hospitalists, along with a senior member from Revenue and Compliance, used the Model for Improvement to create Key Driver Diagram and design interventions (Fig. 1). The outcome measure was wRVU per patient-hospital day. Process measures included the use of Evaluation and Management CPT codes for: high medical decision-making for initial and subsequent hospital inpatient care (99223 and 99233), prolonged discharge (99239), and intensive care and critical care (99477 and 99471). The balancing measure was insurance claims denials. Interventions included faculty education, a billing guide, documentation standardization, and audit with feedback. All PHM patient encounters from January 2023 onward were included. Data were analyzed using statistical control charts to identify special cause variation.

Results: 12,570 PHM patient encounters were analyzed. In the first 5 months of the intervention, wRVUs per patient-hospital day increased from 1.9 to 2.4, exceeding the target (Fig. 2). The use of CPT codes 99223 and 99233 increased from 11% to 53% and 13% to 48%, respectively (Fig. 3a and 3b). The baseline increase observed 3 months before the intervention is attributed to new faculty hires. The use of CPT code 99239 increased from 12% to 39% (Fig. 3c). The use of intensive and critical care codes increased from 0.1 per month during the baseline period to 17.5 per month during the intervention period. The number of denied claims did not change, and there were substantial changes in patient volume or characteristics.

Conclusion(s): We demonstrated an improvement in our billing practices, achieving our target increase in wRVUs. Accurate documentation of high-complexity care by providers is essential to ensure appropriate compensation. Future interventions will focus on sustaining these improvements and optimizing electronic health records use for billing.

Figures 1, 2, 3
Abstract figures.pdf

Figures 1, 2, 3
Abstract figures.pdf