Documenting Clinical Complexity: A Model for Improving Documentation and Billing in Transplant Infectious Diseases

Transplant infectious diseases (TID) clinicians provide complex, high-acuity cognitive care that is frequently undervalued due to inconsistent documentation and underutilization of appropriate evaluation and management (E/M) and billing codes. Limited published data describe billing practices or educational approaches within TID. We evaluated a documentation and coding education model aimed at improving billing accuracy and recognition of TID clinical complexity.

We performed a retrospective analysis of administrative billing data from a tertiary-care academic institution (Medical University of South Carolina) before and after implementation of a structured documentation and billing education initiative (FY 2022-2025). The intervention included division-wide didactic sessions, onboarding training for fellows and faculty, and standardized note template documentation. Outcomes included E/M level distribution for initial and subsequent visits, utilization of G0545 codes, 2025 CMS reimbursement rates, and use of critical care billing.

Following the intervention, high-complexity documentation and billing improved substantially. Level 3 initial consults increased from 40% (2022) to 69% (2025), and Level 3 subsequent visits demonstrated a 36% absolute increase. Overall RVU generation increased by 11.8% during the period. G0545 utilization improved but remained inconsistent. Critical care billing showed slow adoption, largely related to perceived documentation burden and limited familiarity with time-based requirements.

Even a low-intensity documentation and coding education model produced sustained improvement in high-complexity billing within a TID program. Infectious disease-specific codes and critical care billing represent important, underutilized revenue opportunities nationally. Standardized education and workflows may be essential to financial sustainability and workforce support in TID.