Implementing Critical Care Billing on a Pediatric Hospital Medicine Service

Area of Science:

• Pediatric Hospital Medicine
• Quality Improvement Science
• Healthcare Reimbursement

Background:

• Accurate billing for services is crucial for pediatric hospital medicine (PHM) providers managing critically ill children.
• Current critical care code billing rates in eligible PHM patients were suboptimal, averaging 21%.

Purpose of the Study:

• To increase the proportion of critical care codes billed in eligible critically ill PHM patients from 21% to over 50% within six months.
• To improve the documentation supporting critical care billing in this patient population.

Main Methods:

• A six-month quality improvement (QI) initiative was implemented on a PHM service at a tertiary children's hospital.
• Eligibility for critical care billing was based on Centers for Medicaid and Medicare Services definitions, applied to 380 patients.
• Key drivers addressed included clinician knowledge, standardized definitions, documentation practices, and billing behaviors.

Main Results:

• The mean percentage of critical care codes billed increased from 21% to 74%, demonstrating special cause variation.
• This resulted in a 3-fold increase in relative value units (RVUs) and a 4-fold increase in total reimbursement.
• Documentation rates supporting critical care billing rose from 31% to 70%.

Conclusions:

• A systematic QI initiative effectively improved critical care billing and documentation for eligible PHM patients.
• The initiative led to significant increases in RVUs and overall reimbursement, highlighting the impact of targeted interventions.