Implementation of Advanced Care Planning Standardized Documentation and Billing in the Emergency Department: A...

Advanced care planning (ACP) conversations occur frequently in the emergency department (ED). However, such ACP discussions are inconsistently documented and rarely billed.

To implement a quality-improvement project aimed at increasing the frequency of ACP discussions held in the ED and standardizing the related documentation and billing.

The initiative was implemented at an urban academic center affiliated with a cancer center and included a templated note in the electronic health record that recorded ACP documents, surrogate decision-makers, and code status. ACP conversations are billable if discussions lasted > 16 min or if they were included in concurrent critical care time. Retrospective chart review was implemented after 1 year to obtain demographic, diagnostic, clinical, and billing data. In addition to descriptive statistics, we assessed for factors associated with billable (vs. unbillable) ACP time, presence of a designated surrogate decision-maker at the time of presentation, and receipt of palliative care services within 30 days.

Over 12 months, a total of 448 patients had ACP discussions documented using the standardized note. Patients who participated in conversations averaged 72 years of age, and 53% were female. There were preexisting ACP documents in 31.4% of patients, but less than half had previously been uploaded into the medical record. Thirty-day mortality was 29.7%, and repeat visits or readmissions within 30 days occurred in 34.4% of patients discharged after the initial visit. Of encounters with ACP note documented, 6.5% had billable ACP time, 9.6% were eligible for ACP and critical care time, and 38.0% billed for critical care time.

Templated notes can increase consistency of ACP documentation and create a billing opportunity in the ED.