304 - Evaluating Opportunities for Critical Care Billing in Pediatric Status Asthmaticus on a Hospital Medicine Service

Poster Number: 304
Publication Number: 304.124

Background: Missed opportunities in physician billing and coding can lead to substantial financial repercussions. Pediatric hospitalists increasingly care for critically ill patients, yet this work is often not reflected in relative value units (RVUs) or physician billing.

Objective: The primary aim of this study was to assess the difference in RVUs and reimbursement between the evaluation and management current procedural terminology (E/M CPT) code and corresponding critical care code for patients in status asthmaticus admitted to a general care pediatric hospital medicine (PHM) service. A secondary analysis assessed missed opportunities for critical care billing by determining the proportion of patients critically ill on the day of admission, but not evaluated or billed by an attending physician until the next calendar day.

Design/Methods: Retrospective review of patients admitted on continuous albuterol to a PHM service was conducted at an academic children’s hospital from January 2019-June 2023. Critical care was determined using the Centers for Medicare and Medicaid Services definition. This included patients evaluated by an attending physician who remained on continuous albuterol or were escalated to a higher level of care. Proportions were calculated using chi-squared analysis.

Results: There were 280 patients admitted on continuous albuterol, the majority of whom were male (51%), ages 6-20 (58%), with public insurance (77%). Of these patients, 145 (52%) met criteria for critical care billing on the day of admission (Table 1). The estimated difference in reimbursement for these patients totaled $41,859.59 and comprised a 275% increase in potential revenue. The largest difference in reimbursement was attributed to patients ages 2-5 (n=60), generating an increase of 7.97 RVUs and $578.85 per patient. Patients ages 29 days-2 years and 6-20 generated an additional 12.12 RVUs ($534.26) and 1.13 RVUs ($61.63) per patient, respectively (Tables 2 and 3). For the secondary analysis, 123/189 (65%) patients evaluated on the day of admission qualified for critical care, compared to 22/91 (24%) evaluated the next calendar day (p < 0.0001). The 22 patients not billed for critical care on the day of admission or subsequent calendar day represented an additional 161.95 total RVUs and missed revenue of $8,918.83.

Conclusion(s): There was a significant gap in the number of RVUs and reimbursement generated for pediatric patients in status asthmaticus qualifying for critical care on a PHM service. These missed opportunities could negatively impact program operating margins across PHM divisions and children’s hospitals alike.