在使用标准化模板进行选择性脊柱手术的患者的门诊诊所访问的评估和管理编码的差异
Tzu Chuan Yen1, Lasun Oladeji1, Morgan Moon1
1Department of Orthopaedic Surgery, University of Missouri-Columbia, Columbia, MO, USA.
Journal of spine surgery (Hong Kong)
|July 12, 2023
概括
模板临床笔记显著提高了腰部微分隔切除和整体脊椎手术的报销水平,即使在2021年计费变化之后. 这种文档策略减少了计费变化和医疗机构潜在的财务损失.
科学领域:
- 脊柱外科手术的结果
- 医疗补偿分析 医疗补偿分析
- 改善临床文档 改善临床文档
背景情况:
- 医疗文档的变化会影响大型教学机构的准确补偿.
- 2021年评估和管理 (E&M) 计费变化影响了退款流程.
- 标准化文档对于一致的医疗管理和计费至关重要.
研究的目的:
- 为了比较模板和非模板门诊文档之间的报销差异.
- 分析2021年E&M计费变化对退款的影响.
- 评估文档对腰部微切除术和前椎切除术和融合 (ACDF) 程序的报销的影响.
主要方法:
- 从2018-2019年和2021年进行回顾性数据收集.
- 包括接受单级腰部微分隔切除术和ACDF的患者.
- 术前检查的独立编码,以确定计费水平.
主要成果:
- 在2021年之前的腰部微隔膜切除术显示了外科医生之间的计费变化.
- 在2021年后,腰部微分隔切除术的模板说明导致了显著更高的计费 (P=0.013).
- 两个程序的2021年综合数据显示,使用模板票据的计费显著增加 (P<0.05).
结论:
- 临床文档模板尽量减少计费代码的变化.
- 标准化模板对退款产生积极影响,并减轻财务损失.
- 模板在优化第三级护理机构的收入周期方面是有效的.
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