Bundling unbundled charges: a case study in an academic obstetrical practice

In the practice of obstetrics, the non-stress test (NST) and the biophysical profile (BPP) are used to assess fetal well-being. Failure to bundle the NST with the ultrasound BPP will result in a rejected claim if both procedures are performed at the same visit. We implemented a quality improvement program to reduce the number of charge tickets that were coded incorrectly because same-day NST and ultrasound BPP were not bundled. The effectiveness of quality improvement interventions was monitored using statistical process control techniques. The hospital outpatient clinic and department billing processes were in statistical control before any changes were made, but quality was poor: > 40% of same-day NSTs and ultrasound BPPs were coded incorrectly. After clinic processes were changed, the number of incorrectly coded charge tickets decreased over a 9-week period to less than 5% of the total number of BPPs performed each week. This analysis demonstrates that continuous quality improvement is possible in an academic practice operating within a relatively inflexible university outpatient clinic environment.