370 - A Quality Improvement Project to Increase Relative Value Unit Generation from Documentation in the Pediatric Emergency Department

Poster Number: 370
Publication Number: 370.22

Background: Medical record documentation drives billing for clinical services. We observed that documentation was contributing to a financial deficit and provider dissatisfaction.

Objective: The primary aims of this quality improvement (QI) project were to 1) reduce monthly average level of service (LOS) billing of 99282 per visit by 20%, and 2) increase monthly average RVU generation per visit by 5% over 12 months.

Design/Methods: Using the model for improvement, we formed a multidisciplinary team to set goals, determine metrics, and plan project activities. A pre-survey queried stakeholder perceptions on documentation’s impact on work satisfaction and informed the project’s Pareto Chart and Key Driver Diagram (Fig. 1). Key barriers identified included Electronic Health Record inefficiencies and lack of stakeholder knowledge regarding documentation’s impact on RVU generation. PDSA interventions included readily available fact sheets, an integrated LOS calculator, standardized note templates, and monthly data reviews (Fig. 1).

Primary outcomes were analyzed via statistical process control. The impacts of the “tripledemic” and proportion of low acuity encounters (Emergency Severity Index 4&5) on our outcomes were monitored. We measured “billing appropriateness” as a balancing measure by comparing provider billed LOS to LOS determined by our billers.

We surveyed stakeholders nine months into the project to determine time requirement, ease of use, and satisfaction with interventions. Chi-square tests compared the proportion of pre vs. post respondents agreeing or strongly agreeing with survey prompts from the National Electronic Health Records survey.

Results: The project began August 2022, the first PDSA intervention was October 2022 (Fig. 2). Billing of LOS 99282 decreased by 23% in January 2023. RVUs per visit increased by 6% in February 2023. Neither the “tripledemic” nor the proportion of low acuity encounters explained the improved outcomes.

Audit of 622 patient records in February 2023 revealed that physicians billed “appropriately” 78% of the time with equal direction of discordant billing.

The pre- and post-surveys were completed by 57 and 52 stakeholders, respectively. Stakeholders reported improved perceptions of the time dedicated to documentation (38% vs. 61%; p = 0.02); ease of documentation (46% vs. 69%; p = 0.02); and overall satisfaction with documentation (6% vs. 49%; p < 0.01).

Conclusion(s): Using QI methodology, we increased LOS billing, RVU generation, and improved the ED provider documentation experience. Ongoing chart audits and provider feedback will ensure sustainability.