Clinical Instructor Boston Children's Hospital Boston, Massachusetts, United States
Background: Pediatric Hospital Medicine (PHM) programs play a vital role in both community and academic hospitals, yet financial sustainability can be jeopardized by suboptimal inpatient professional fee coding. The viability of PHM service lines depends on accurate documentation and the appropriate use of Current Procedural Terminology (CPT) evaluation and management (E/M) coding. At our institution, we identified opportunities to enhance admission CPT E/M coding and noted a lack of awareness among providers regarding optimal billing practices. Objective: Our SMART aim was to improve mean Admission Total RVU/Encounter from 4.39 to 4.8 within one year. Design/Methods: We utilized the Model for Improvement as a framework for this work. A key stakeholder needs assessment revealed variability in professional fee billing practices and a need for further education as key drivers for improvement. Interventions implemented included interactive education, professional fee billing documentation & guideline development, Q&A sessions, and audits with feedback. The goal benchmark was determined through a review of current literature and an expert evaluation of appropriate CPT E/M coding from a random sampling of 200 charts. Change management concepts were employed when developing and sustaining interventions. Plan-Do-Study-Act (PDSA) cycles adapted to changes in national billing guidelines. The primary outcome was mean admission RVU/Encounter; process measures included coding accuracy rate measured by eligible encounters accurately utilizing CPT E/M code 99477, and balancing measures focused on misclassification error rates. Results: RVU/Encounter analysis from July 2018 to March 2024 showed a notable improvement in performance, with the mean admission Total RVU/Encounter increasing from 4.39 pre-intervention to 4.83 post-intervention with sustained improvement over 28 months, which was the result of special cause variation. Run Charts displaying an increase in the utilization of CPT E/M code 99477 post-intervention suggests implementation of materials learned during educational sessions.
Conclusion(s): This improvement work outlines an effective strategy to enhance professional fee billing accuracy for PHM providers. By fostering a culture of continuous improvement in documentation practices, this initiative also supports inpatient care and contributes to better patient management. Moving forward, we aim to scale this approach to optimize professional fee billing and documentation practices across additional service lines within our institution, further strengthening the operational sustainability of inpatient specialties.
