Improving Capture of Care Complexity on a Pediatric Acute Care Cardiology Unit
Presented By:
J.E. Hansen, MD; E. Clark CPC, CDEO; C. Goldberg MD, MS; S. Pasquali MD, MHS; C. Strohacker MD
C.S. Mott Children's Hospital, University of Michigan
hjesse@med.umich.eduOverview:
Purpose: Patient acuity and associated care complexity can vary widely across pediatric cardiac patients cared for on the acute care cardiology or stepdown unit. Understanding and documenting these factors significantly impacts coding and billing and hence professional revenue capture; however there are many barriers including limited physician knowledge, physician workload, and limited communication and collaboration across coding and physician teams. After conducting external benchmarking demonstrating under-coding of high acuity patients on our unit, we designed and implemented an improvement project to address these barriers. Our global aim was to enhance overall revenue through appropriate capture of acuity and level of care.
Project Design: Using the Model for Improvement methodology, we identified key drivers of change and implemented Plan-Do-Study-Act (PDSA) cycles starting with N=1 trials and ramping to unit-wide tests. To address known barriers, our efforts focused on enhanced collaboration & communication between physician and coding teams, team education, IT solutions including electronic medical record (EMR)-based templates and tools to maximize efficiency, and real-time physician support and case review from a coder with domain expertise in pediatric cardiac care. Our primary outcome metric was relative value units (RVUs)/patient hospital day. Our primary balance measure was concordance between physician selected level of service vs. coder review. All materials were reviewed and approved by institutional revenue cycle and compliance departments. Statistical process control (run, xbar, and s charts) were used to analyze change over time in the pre- (18 months) vs. post- (12 months) intervention period.
Results: A total of 6465 patient days were analyzed from June 1 2021 to May 31 2022. The pre-intervention baseline was 1.4 RVUs/patient day. In the first month post-intervention, there was an increase outside of 3-sigma control limits indicating a significant change early in the intervention. Through 12 months of intervention, RVUs/patient day increased by 57% to 2.2 RVUs/patient day with a 441% increase in intensive care and 379% increase in critical care billing, and >$500,000 overall in excess revenue. The most common discordance between physician and expert coding review remains under-coding by the physician.
Conclusion: Using Model for Improvement methods and a multifaceted approach including enhanced education, collaboration & communication, and EMR-based IT solutions, our intervention was successful in enhancing appropriate capture of acuity and downstream revenue on the acute care unit. Ongoing efforts are utilizing similar methods across other areas of the heart center.
Project Design: Using the Model for Improvement methodology, we identified key drivers of change and implemented Plan-Do-Study-Act (PDSA) cycles starting with N=1 trials and ramping to unit-wide tests. To address known barriers, our efforts focused on enhanced collaboration & communication between physician and coding teams, team education, IT solutions including electronic medical record (EMR)-based templates and tools to maximize efficiency, and real-time physician support and case review from a coder with domain expertise in pediatric cardiac care. Our primary outcome metric was relative value units (RVUs)/patient hospital day. Our primary balance measure was concordance between physician selected level of service vs. coder review. All materials were reviewed and approved by institutional revenue cycle and compliance departments. Statistical process control (run, xbar, and s charts) were used to analyze change over time in the pre- (18 months) vs. post- (12 months) intervention period.
Results: A total of 6465 patient days were analyzed from June 1 2021 to May 31 2022. The pre-intervention baseline was 1.4 RVUs/patient day. In the first month post-intervention, there was an increase outside of 3-sigma control limits indicating a significant change early in the intervention. Through 12 months of intervention, RVUs/patient day increased by 57% to 2.2 RVUs/patient day with a 441% increase in intensive care and 379% increase in critical care billing, and >$500,000 overall in excess revenue. The most common discordance between physician and expert coding review remains under-coding by the physician.
Conclusion: Using Model for Improvement methods and a multifaceted approach including enhanced education, collaboration & communication, and EMR-based IT solutions, our intervention was successful in enhancing appropriate capture of acuity and downstream revenue on the acute care unit. Ongoing efforts are utilizing similar methods across other areas of the heart center.
