Attending documentation contribution to billing at an academic ED with an electronic health record

In emergency medicine (EM), patient care documentation serves many functions, including supporting reimbursement. In addition, many electronic health record systems facilitate automatically populating certain data fields. As a result, in the academic model, the attending's note may now more often recapitulate many of the same elements found in the resident's or physician assistant's (PA) note. We sought to determine the value of additional attending documentation, and how often the attending documentation prevented a downcoding event.

This retrospective, cross-sectional study was exempted by the Institutional Review Board. We randomly reviewed 10 charts for each attending physician during the study period. Outcome measures included the frequency of prevented downcoding events, and the difference in this incidence between residents and PAs.

530 charts were identified, but 6 were excluded as these patients left without being seen. 524 charts remained, of which 286 (45%) notes were written by residents and 238 (55%) notes were written by PAs. Attending documentation prevented 16 (3%) downcoding events, of which 11 were in patient encounters documented by residents and 5 were in encounters documented by PAs (p=0.057).

In this study of an academic medical center documentation model with an EHR, EM attending documentation of the history of present illness, review of systems, physical exam, and medical decision making portions prevented downcoding in a small number of cases. In addition, there was no significant difference in the incidence of prevented downcoding events between residents and PAs.