A Multiphase Quality Improvement Project to Increase Relative Value Unit Generation Through Documentation Practices...

Documentation is essential to patient care, research, and financial sustainability. In our pediatric emergency department (PED), existing documentation practices contributed to financial deficits and decreased workplace satisfaction.

To increase the monthly average relative value unit (RVU) per encounter by 10% over 2 years. Phase 1 aimed to reduce level of service (LOS) 99282 billing by 20%. Phase 2 targeted a 20% increase in LOS 99285 billing and aimed for 90% of admitted patients to be billed at LOS 99285.

Using the Model for Improvement and iterative Plan-Do-Study-Act (PDSA) cycles, our team implemented interventions including a billing dot phrase, revised note templates, billing reference sheets, and an LOS calculator. Outcomes were tracked using statistical process control charts. Balancing measures included coding concordance (chart audit, run charts) and provider impact (pre/post-surveys, run charts for note length, and documentation time).

The average RVU per encounter increased by 11%. LOS 99282 billing decreased by 25%, whereas LOS 99285 billing increased from 9% to 13%, and from 50% to 70% among admitted patients. Billing discordance remained at 28%. Provider satisfaction improved: perceived ease of documentation rose from 46% to 69%, and overall satisfaction from 6% to 49%. Documentation time remained stable (6.6 min), and note length decreased.

Targeted documentation interventions improved both RVU generation and provider satisfaction. Future work will focus on optimizing critical care documentation and enhancing collaboration with professional billers to reduce coding discordance.