Pediatric Hospitalist Fellow Nicklaus Children’s Hospital Miami, Florida, United States
Background: In healthcare, accurate billing and coding are essential. Upcoding can lead to fraud and overbilling, while downcoding can have an impact on productivity targets and can account for significant revenue loss. In January 2023, CMS released new guidelines for billing and documentation , which required training both clinicians as well as coders. A recent article by DeCicco demonstrated that implementing quality improvement tactics for inpatient note documentation and coding can accurately reflect the complexity of care delivered and generate more revenue. Objective: To improve accurate E/M billing codes within the hospitalist division from 82% in July 2023 to 95% in 6 months. To improve wRVUs to an average of 1.9, the mean pediatric hospitalist national benchmark per Society of Hospital Medicine 2023 report. As a secondary outcome, evaluate the distribution of initial billing codes: 99221 vs 99222 vs 99223, distribution of subsequent billing codes: 99231 vs 99232 vs 99233, percentage of downcodes, percentage of upcodes, and wRVU per encounter. Design/Methods: Monthly report beginning July 2023 serves as baseline data which included the number of encounters, type of encounters, wRVU, percent of upcodes, and percent of downcodes amongst hospitalist. Compared data to national benchmarks and performed internal chart review to validate data included on the reports developed by third party billing company. Collaborated with coders to improve accurate documentation and coding by providing feedback and education specifically on pediatric illnesses and pediatric risk. Monthly meetings and email communications established with clinicians for individualized feedback and education on appropriate documentation and coding. Developed documentation addendums for high risk conditions to help justify appropriate billing. Three members of the Hospitalist division attended a PHM conference and two billing webinars and shared experience and tips. This QI project was deemed to be IRB exempt.
