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Implementing Critical Care Billing on a Pediatric Hospital Medicine Service
Suzanne N Ramazani1, Marisa Mauro2, Bethany Marbaker2
1Division of Pediatric Hospital Medicine, Golisano Children's Hospital, University of Rochester Medical Center.
Insights
Pediatric hospital medicine (PHM) billing for critically ill patients improved significantly through a quality improvement initiative. Critical care code billing increased from 21% to 74%, boosting reimbursement and relative value units (RVUs).
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.
Background And Objective:
As more critically ill patients are managed by pediatric hospital medicine (PHM), accurately capturing the services provided and corresponding reimbursement is essential for pediatric hospitalists. We sought to increase the proportion of critical care codes billed in eligible critically ill PHM patients from a baseline mean of 21% to more than 50% over 6 months.
Methods:
A quality improvement (QI) initiative was conducted at a tertiary care children's hospital on the PHM service from November 2023 through April 2024. Eligibility for critical care billing was determined by the Centers for Medicaid and Medicare Services definition and applied to patients requiring at least 5 L of high-flow nasal cannula or continuous albuterol on attending physician evaluation (n = 380). Key drivers included clinician knowledge of critical care billing, the application of standardized definitions, appropriate documentation, and clinician billing practices. The outcome measure was the percentage of critical care codes billed in eligible critically ill patients, and the process measure was the percentage of charts containing documentation to support critical care billing.
Results:
The mean percentage of critical care codes increased from 21% to 74%, with special cause variation observed. This led to a 3-fold increase in relative value units (RVUs) and a 4-fold increase in the total estimated reimbursement generated. The mean percentage of charts with documentation to support critical care billing increased from 31% to 70%.
Conclusions:
A QI initiative to systematically implement critical care billing in eligible PHM patients was associated with an improvement in critical care billing and documentation, significantly increasing RVUs and reimbursement.
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