Charge capture in the BICU: Increasing revenue by improving documentation behaviors

Area of Science:

• Healthcare Administration
• Medical Billing and Coding
• Clinical Documentation Improvement

Background:

• Healthcare provider documentation is crucial for accurate reimbursement, yet patient encounters are frequently under-coded.
• Deficiencies in medical decision making (MDM) documentation lead to revenue loss as coders cannot assess physician effort without clear records.
• Physicians at a regional burn center experienced below-average reimbursement, suspecting documentation flaws as the primary cause.

Purpose of the Study:

• To enhance MDM documentation quality within a burn center setting.
• To increase the number and service levels of billable patient encounters.
• To improve overall unit revenue through more thorough and accurate clinical documentation.

Main Methods:

• Developed and implemented two key resources: a pocket card for encounter documentation recall and a standardized electronic medical record (EMR) template.
• Mandated the use of the standardized EMR template for all medical professionals rotating through the Burn Intensive Care Unit (BICU).
• Compared documentation and coding data from July-October 2019 (pre-intervention) with July-October 2021 (post-intervention).

Main Results:

• Inpatient subsequent visit codes demonstrated an average increase in billable encounters of 1500% post-intervention.
• Specific subsequent visit codes (99231, 99232, 99233) saw dramatic increases of 142%, 2158%, and 2200%, respectively.
• Billable encounters replaced non-reimbursable global encounters (99024), indicating improved documentation of non-global patient issues.

Conclusions:

• Focused efforts to improve physician documentation, particularly MDM, can yield significant improvements in healthcare unit profitability.
• The implemented pocket card and EMR template effectively increased documentation thoroughness and recall, leading to higher reimbursement levels.
• Physician buy-in, though challenging, was achieved through consistent training and feedback, highlighting the importance of education in billing and coding processes.