Quality Improvement: Effect of Standardized Plastic Surgery Consultation Note Templates on Charge Capture

Effective medical record documentation is imperative for both patient care and reimbursement for care provided. The purpose of this study was to compare coding/billing patterns for plastic surgery consultations before and after implementation of a standardized documentation protocol.

Standardized hand, facial trauma, and general plastic surgery consult note templates were created. Following institutional approval, records were reviewed for all plastic surgery consultations from January to October 2019. Template notes were universally implemented in July 2019. Medical coding was performed by a certified professional coder using the 1995 Evaluation and Management Review Worksheet. Coding/billing patterns between groups were compared with and without standardized documentation using univariate analysis.

Seventy-five consecutive preimplementation consult notes and 75 consecutive postimplementation consult notes were selected for review. Each group included 25 hand, 25 facial trauma, and 25 general plastic surgery consultation notes. The history and physical examination components of the visit code were more frequently coded as "comprehensive"postimplementation (P = 0.000). There was no significant difference in coding for medical decision making between the two groups (P = 0.340). The final visit code was significantly higher in the postimplementation group (45.3% 99254/99284 versus 2.7%, P = 0.000), and the charges were significantly higher post implementation-average charge per consult $250 versus $203 (P = 0.000) with a 22.8% increase in total charges generated.

Utilization of standardized consultation note templates increases the accuracy of coding and associated billing of inpatient and emergency department plastic surgery consultations through documentation and reflection of level of service provided.