优化居民收费捕获与消失的帮助文本在笔记模板中的优化
Taylor B Martin1, Douglas S Bell2, Jeffrey A Gornbein3
1Division of Medicine-Pediatrics, Department of Medicine, UCLA Health System, Los Angeles, California, United States.
在电子健康记录中消失的帮助文本显著减少了居民对不正确的当前程序术语 (CPT) 代码的使用. 这种工具提高了评估和管理 (E/M) 编码的准确性,减少了对主治医生的调整的需求.
科学领域:
- 医疗信息学 医疗信息学
- 医疗保健管理局的管理.
- 临床文档 临床文档
背景情况:
- 评估和管理 (E/M) 服务的准确编码对于医疗补偿和质量评估至关重要.
- 医疗住院人员在选择正确的当前程序术语 (CPT) 代码时经常面临挑战.
- 标准化笔记模板在临床环境中被广泛使用,以简化文档流程.
研究的目的:
- 评估在标准化笔记模板中整合消失的帮助文本的有效性,以改善E/M服务的居民CPT代码选择.
- 为了减少临床医生修改CPT代码的频率,作为居民编码准确性的代理.
主要方法:
- 一个消失的帮助文本总结了E / M编码要求被嵌入到为儿科急诊护理居民的标准化笔记模板中.
- 一个干预组 (PGY 1居民) 使用了带有帮助文本的模板,而一个控制组 (PGY 2-3居民) 使用了没有帮助文本的相同模板.
- 测量的主要结果是临床医生CPT代码变化的发生率,使用后勤回归分析.
主要成果:
- 使用帮助文本的居民显示,临床医生对CPT代码的更改率明显较低 (22.1%vs30.6%).
- 在不同培训水平 (PGY 1和PGY 2-3) 中,CPT代码调整的减少是一致的.
- 多变量分析证实,帮助文本的使用独立地与CPT代码修改的大幅减少有关 (OR = 0.28).
结论:
- 在居民笔记模板中实现消失的帮助文本是提高E/M编码准确性的有希望的策略.
- 这项干预措施使得临床医生对CPT代码的调整需求显著减少,这表明住院人员的表现有所改善.
- 这些发现表明,这种辅助文本功能在改善各种医疗保健环境中的临床文档和编码方面具有更广泛的适用性.
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