Improving Newborn Professional Billing at a Community Hospital

In community hospital medicine programs, newborns often represent a large patient population with diverse clinical needs. Capturing the care provided through professional billing provides the foundation for division revenue; however, provider knowledge on how to optimally bill is often lacking. Our group underused Hospital Care current procedural terminology (CPT) evaluation and management (E/M) codes for newborns requiring increased monitoring, diagnostic interventions, or therapy. Our aim was to increase use of Level 2 and 3 Hospital Care CPT E/M codes for newborns from 1% to 15%.

The process improvement project was conducted from October 2022 through October 2023 in the mother-baby unit of a community hospital with approximately 1800 births per year. Key drivers for underuse of Hospital Care CPT E/M codes were identified, and interventions were developed that included educational sessions, real-time guidance, and improved access to the billing codes. All newborn initial and subsequent care professional billing codes were included. We used retrospective chart review to determine whether clinical care and documentation supported the use of the codes.

The proportion of Level 2 and 3 Hospital Care CPT E/M codes increased to 17%. This increase represented a 7% increase in work relative value units and an estimated increase in revenue of $37 805 per 10 000 billing encounters. Review of select charts demonstrated appropriate documentation to support use of the codes 72% of the time.

Providing education and tools on professional billing for newborns improved appropriate billing code use and optimized revenue at 1 community hospital.