- Email: [email protected]
Turning whine into wine: the fiscal impact of comprehensive documentation and billing for nonoperative pediatric surgical services
Journal of Pediatric Surgery (2006) 41, 1093 – 1095
www.elsevier.com/locate/jpedsurg
Turning whine into wine: the fiscal impact of comprehensive documentation and billing for nonoperative pediatric surgical services Gerald Gollin*, Donald Moores Division of Pediatric Surgery, Loma Linda University School of Medicine and Children’s Hospital, Loma Linda, CA 92354, USA Index words: Billing; E&M codes; Pediatric surgery
Abstract Purpose: Some pediatric surgeons rarely document nonoperative services, believing that the reimbursement provided for such care is negligible. We evaluated the impact of comprehensive documentation and billing for nonoperative, pediatric surgical care. Methods: All bills submitted for inpatient, nonoperative care for 1 year were reviewed. Total receipts for documented admissions, consultations, critical care, and daily care were determined. The Evaluation and Management code billed for each service was recorded, and the total and average payments attributable to each Evaluation and Management code were calculated. Results: Fifty-six percent of services were covered by Medicaid and 26% by a commercial insurer. There were 607 billed admission history and physical exams for which reimbursement totaled $43,493. Critical care services were provided to 49 patients and yielded $8964 in payments. Six hundred thirtynine inpatient consultations were performed with a reimbursement of $42,830. Daily care services were billed 1044 times and produced $71,579 in payments. Overall reimbursement for documented, nonoperative services was $166,866. This represented 16.2% of total, noncontracted income for the practice. Conclusion: Despite a payer mix heavily weighted toward Medicaid, comprehensive documentation and billing for nonoperative services increased total, noncontracted reimbursement by almost 20% over what it would have been had only operative services been billed. The yield from properly documented, nonoperative care can be substantial. D 2006 Elsevier Inc. All rights reserved.
In the1980s, Medicare administrators discovered that many physicians were billing for services that had not been provided. Subsequently, with the initiation of Medicare’s mandatory claims review in 1992 and the implementation of the new Physician’s Current Procedural Terminology Evaluation and Management (E&M) codes, the scrutiny
* Corresponding author. Tel.: +1 909 558 4619; fax: +1 909 558 7978. E-mail address: [email protected] (G. Gollin). 0022-3468/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2006.02.009
applied by government and private payers to physicians’ documentation of services increased dramatically [1,2]. In response to these policy changes, rather than increasing their documentation, some surgeons elected to stop billing for nonoperative care, believing that it was not worth their effort. For a number of surgical specialties, this may, in fact, be true. However, most of the inpatient cases managed by a pediatric surgeon are urgent or emergent hospital admissions or consultations, and a significant proportion of these, particularly trauma cases, are nonoperative. We hypothe-
1094
G. Gollin, D. Moores
Table 1 Documentation requirements for inpatient E&M services including the frequency, charge, average payment, and percent reimbursement for each type and level of service Required components Service
History
Type/Level
History of present illness
Review of systems
Past, family, and social history
Systems
Frequency
Charge ($)
Average payment (% reimbursement), $
4 4 4
2 10 10
1 3 3
5 8 8
149 419 35
194 312 407
49.94 (26) 71.92 (23) 123.03 (30)
1 1 4 –
0 1 2 –
0 0 1 –
1 2 5 –
319 572 27 126
98 148 207 177
35.24 35.28 55.42 58.88
(36) (24) (27) (33)
1 1 4 4
0 1 2 10
0 0 1 3
1 2 5 8
5 39 364 238
130 207 276 382
39.45 48.48 56.33 73.83
(33) (23) (20) (19)
50 18
538 259
H&P 99221 99222 99223 Daily care 99231 99232 99233 99238a Consult 99251 99252 99253 99254 Critical care 99291 99292 a
Exam
First 60 min Additional 30 min
121.58 (24) 62.41 (24)
Discharge day.
sized that the fiscal impact of documentation and billing for the nonoperative care provided by pediatric surgeons might be substantial. We evaluated the reimbursement obtained from a practice of comprehensive documentation of nonoperative care.
1. Methods All bills submitted by the Division of Pediatric Surgery at the Loma Linda University Children’s Hospital for inpatient, nonoperative care between July 2002 and June 2003 were reviewed. Bills were submitted by 3 full-time pediatric surgeons on a service staffed by 3 general surgical residents. The payer distribution was determined. During the study period, an attending surgeon dictated a history and physical exam (H&P) for every patient admitted and dictated a note for every consultation and critical care service provided. Critical care services were limited to the initial management of complex trauma patients by an attending surgeon. No ventilator management was provided by the surgical staff. An attending surgeon independently documented the required components of billable daily care [3] for all admitted or consulted patients on every day in which the pediatric surgery service provided care. Total receipts for documented admission H&Ps, consultations, critical care, daily care, and discharges were tabulated. The E&M code billed for each service was recorded as well as the nature of the service provided (preoperative care, nonoperative trauma management, other nonoperative care, and consultations). The total payments
for each type and level of nonoperative service was calculated. The reimbursement rate for each E&M code was determined by dividing the average payment by the amount charged. The total payments and reimbursement rates for operative care, including billable minor hospital procedures and office-based services were determined. The E&M code billed for every H&P, consultation, and critical care service was validated by a trained coder based upon the criteria listed in Table 1 and, if necessary, adjusted to reflect the documentation supplied in the medical record to maintain compliance with regulations. The average time required for documentation of an H&P (E&M 99222) was determined by timing 5 dictations of each attending surgeon. The charges for transcription services were determined. This study was deemed exempt from review by the Institutional Review Board of Loma Linda University.
2. Results During the period of the study, 56% of services were covered by Medical (the California Medicaid program) and 26% by a commercial insurer. The remainder were self-pay cases (negligible reimbursement) under a capitated plan (no direct reimbursement) or were covered by Medicare (Fig. 1). The level of care that was provided and documented was independent of insurance status. There were 603 billed admission H&Ps including 359 for trauma. Reimbursement for admission H&Ps (E&M codes
Turning whine into wine
Fig. 1 Payer distribution for nonoperative services. Medical is the California Medicaid program. Contracted medical and contracted commercial insurance include preferred provider organizations and health maintenance organizations.
99221-99223) totaled $43,493. Billable critical care services (E&M codes 99291 and 99292) were provided to 49 trauma patients with a reimbursement of $8964. Six hundred thirtynine inpatient consultations (445 preoperative) were performed. Reimbursement for consultations (E&M codes 99251-99254) totaled $42,830. Daily care or discharge services were billed 1044 times, including 330 consult patient visits. Reimbursement for daily care and discharges (E&M codes 99231, 99232, 99238) totaled $71,579. The frequency of billing and average reimbursement for each type and level of service are listed in Table 1. Overall reimbursement for documented, nonoperative services was $166,866. The total payment for operative services was $1,006,819 (31% rate of reimbursement), and for office consultations was $23,218 (28% rate of reimbursement). Therefore, inpatient, nonoperative services accounted for 16.2% of total, noncontracted reimbursement for the practice.
1095 surgeon, a plastic surgeon, surgical oncologist, or otolaryngologist may also be better reimbursed for the operative care that they provide because of the stratified reimbursement scales for adult and pediatric procedures. For these reasons, some surgeons have ignored documentation and billing for nonoperative care. Only in specialties heavily weighted toward nonoperative management such as trauma/critical care and burn surgery have organized efforts been made to capture reimbursement for nonoperative services [4-7]. When nonoperative care is billed, it is essential that documentation be meticulous to maintain compliance with regulations and avoid fraud charges. To make the process of recording charges more efficient and less onerous, we have used an intranet-based, Filemakerk database to record charges on inpatients on a daily basis so that bills may be prepared on the day that a service is provided. This system is further facilitated by personal digital assistants (PDAs) that make the patient database portable and allow each surgeon to enter charge data for their patients as they visit them and download the data later. The reimbursement rates for nonoperative services (19%36%) were comparable to the average reimbursement rate for operative services of 31%. Furthermore, the time (about 10 minutes per typical H&P) and the transcription costs (covered by the hospital) required for documentation of nonoperative services were nominal. Although some pediatric surgeons focus mostly upon operative services, the yield from properly documented, nonoperative care can be substantial. In this era of diminished reimbursement for pediatric surgical procedures, aggressive documentation and billing for nonoperative care can help to recoup some of the money that had once been more available for salaries and academic activities. In our practice, we have concluded that documentation of nonoperative care is not only an integral part of resident supervision but is well-compensated relative to the amount of time that it consumes.
3. Discussion Despite a payer mix that was heavily weighted toward Medicaid, comprehensive documentation and billing for nonoperative services increased total, noncontracted reimbursement by almost 20% over what would have been obtained had only operative services been billed. The average payment for each E&M code (Table 1) was diminished by the inclusion of self-pay and capitated cases for which there was usually no reimbursement for the service provided. In addition, there was no payment for some services provided to patients covered by Medicaid or a commercial carrier when the care was contractually uncovered. Care was provided irrespective of insurance status. Pediatric surgeons with a high volume of trauma cases and emergency admissions and consultations provide a substantial amount of inpatient, nonoperative care. Although engaging in less nonoperative care than a pediatric
References [1] Seare JG. Medical documentation. Salt Lake City (Utah)7 Medicode; 1993. p. i - ii. [2] Driscoll P, editor. Ingenix coding lab: medical billing basics. 5th ed. Salt Lake City (Utah)7 Ingenix; 2002. p. 97. [3] Gordy TR, editor. Current procedural terminology: CPT 2004. Chicago (Ill)7 American Medical Association; 2004. p. 1 - 32. [4] Reed RL, Davis KA, Silver GM, et al. Reducing trauma payment denials with computerized collaborative billing. J Trauma 2003;55: 762 - 70. [5] Fakhry SM. Cilling, coding, and documentation in the critical care environment. Surg Clin North Am 2000;80:1067 - 83. [6] Heistein JB, Coffey RA, Buchele BA, et al. Development and initiation of computer generated documentation for burn patient care. J Burn Care Rehabil 2002;23:273 - 9. [7] Rogers FB, Osler T, Shackford SR, et al. Charges and reimbursement at a rural level 1 trauma center: a disparity between effort and reward among professionals. J Trauma 2003;54:9 - 15.
www.elsevier.com/locate/jpedsurg
Turning whine into wine: the fiscal impact of comprehensive documentation and billing for nonoperative pediatric surgical services Gerald Gollin*, Donald Moores Division of Pediatric Surgery, Loma Linda University School of Medicine and Children’s Hospital, Loma Linda, CA 92354, USA Index words: Billing; E&M codes; Pediatric surgery
Abstract Purpose: Some pediatric surgeons rarely document nonoperative services, believing that the reimbursement provided for such care is negligible. We evaluated the impact of comprehensive documentation and billing for nonoperative, pediatric surgical care. Methods: All bills submitted for inpatient, nonoperative care for 1 year were reviewed. Total receipts for documented admissions, consultations, critical care, and daily care were determined. The Evaluation and Management code billed for each service was recorded, and the total and average payments attributable to each Evaluation and Management code were calculated. Results: Fifty-six percent of services were covered by Medicaid and 26% by a commercial insurer. There were 607 billed admission history and physical exams for which reimbursement totaled $43,493. Critical care services were provided to 49 patients and yielded $8964 in payments. Six hundred thirtynine inpatient consultations were performed with a reimbursement of $42,830. Daily care services were billed 1044 times and produced $71,579 in payments. Overall reimbursement for documented, nonoperative services was $166,866. This represented 16.2% of total, noncontracted income for the practice. Conclusion: Despite a payer mix heavily weighted toward Medicaid, comprehensive documentation and billing for nonoperative services increased total, noncontracted reimbursement by almost 20% over what it would have been had only operative services been billed. The yield from properly documented, nonoperative care can be substantial. D 2006 Elsevier Inc. All rights reserved.
In the1980s, Medicare administrators discovered that many physicians were billing for services that had not been provided. Subsequently, with the initiation of Medicare’s mandatory claims review in 1992 and the implementation of the new Physician’s Current Procedural Terminology Evaluation and Management (E&M) codes, the scrutiny
* Corresponding author. Tel.: +1 909 558 4619; fax: +1 909 558 7978. E-mail address: [email protected] (G. Gollin). 0022-3468/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2006.02.009
applied by government and private payers to physicians’ documentation of services increased dramatically [1,2]. In response to these policy changes, rather than increasing their documentation, some surgeons elected to stop billing for nonoperative care, believing that it was not worth their effort. For a number of surgical specialties, this may, in fact, be true. However, most of the inpatient cases managed by a pediatric surgeon are urgent or emergent hospital admissions or consultations, and a significant proportion of these, particularly trauma cases, are nonoperative. We hypothe-
1094
G. Gollin, D. Moores
Table 1 Documentation requirements for inpatient E&M services including the frequency, charge, average payment, and percent reimbursement for each type and level of service Required components Service
History
Type/Level
History of present illness
Review of systems
Past, family, and social history
Systems
Frequency
Charge ($)
Average payment (% reimbursement), $
4 4 4
2 10 10
1 3 3
5 8 8
149 419 35
194 312 407
49.94 (26) 71.92 (23) 123.03 (30)
1 1 4 –
0 1 2 –
0 0 1 –
1 2 5 –
319 572 27 126
98 148 207 177
35.24 35.28 55.42 58.88
(36) (24) (27) (33)
1 1 4 4
0 1 2 10
0 0 1 3
1 2 5 8
5 39 364 238
130 207 276 382
39.45 48.48 56.33 73.83
(33) (23) (20) (19)
50 18
538 259
H&P 99221 99222 99223 Daily care 99231 99232 99233 99238a Consult 99251 99252 99253 99254 Critical care 99291 99292 a
Exam
First 60 min Additional 30 min
121.58 (24) 62.41 (24)
Discharge day.
sized that the fiscal impact of documentation and billing for the nonoperative care provided by pediatric surgeons might be substantial. We evaluated the reimbursement obtained from a practice of comprehensive documentation of nonoperative care.
1. Methods All bills submitted by the Division of Pediatric Surgery at the Loma Linda University Children’s Hospital for inpatient, nonoperative care between July 2002 and June 2003 were reviewed. Bills were submitted by 3 full-time pediatric surgeons on a service staffed by 3 general surgical residents. The payer distribution was determined. During the study period, an attending surgeon dictated a history and physical exam (H&P) for every patient admitted and dictated a note for every consultation and critical care service provided. Critical care services were limited to the initial management of complex trauma patients by an attending surgeon. No ventilator management was provided by the surgical staff. An attending surgeon independently documented the required components of billable daily care [3] for all admitted or consulted patients on every day in which the pediatric surgery service provided care. Total receipts for documented admission H&Ps, consultations, critical care, daily care, and discharges were tabulated. The E&M code billed for each service was recorded as well as the nature of the service provided (preoperative care, nonoperative trauma management, other nonoperative care, and consultations). The total payments
for each type and level of nonoperative service was calculated. The reimbursement rate for each E&M code was determined by dividing the average payment by the amount charged. The total payments and reimbursement rates for operative care, including billable minor hospital procedures and office-based services were determined. The E&M code billed for every H&P, consultation, and critical care service was validated by a trained coder based upon the criteria listed in Table 1 and, if necessary, adjusted to reflect the documentation supplied in the medical record to maintain compliance with regulations. The average time required for documentation of an H&P (E&M 99222) was determined by timing 5 dictations of each attending surgeon. The charges for transcription services were determined. This study was deemed exempt from review by the Institutional Review Board of Loma Linda University.
2. Results During the period of the study, 56% of services were covered by Medical (the California Medicaid program) and 26% by a commercial insurer. The remainder were self-pay cases (negligible reimbursement) under a capitated plan (no direct reimbursement) or were covered by Medicare (Fig. 1). The level of care that was provided and documented was independent of insurance status. There were 603 billed admission H&Ps including 359 for trauma. Reimbursement for admission H&Ps (E&M codes
Turning whine into wine
Fig. 1 Payer distribution for nonoperative services. Medical is the California Medicaid program. Contracted medical and contracted commercial insurance include preferred provider organizations and health maintenance organizations.
99221-99223) totaled $43,493. Billable critical care services (E&M codes 99291 and 99292) were provided to 49 trauma patients with a reimbursement of $8964. Six hundred thirtynine inpatient consultations (445 preoperative) were performed. Reimbursement for consultations (E&M codes 99251-99254) totaled $42,830. Daily care or discharge services were billed 1044 times, including 330 consult patient visits. Reimbursement for daily care and discharges (E&M codes 99231, 99232, 99238) totaled $71,579. The frequency of billing and average reimbursement for each type and level of service are listed in Table 1. Overall reimbursement for documented, nonoperative services was $166,866. The total payment for operative services was $1,006,819 (31% rate of reimbursement), and for office consultations was $23,218 (28% rate of reimbursement). Therefore, inpatient, nonoperative services accounted for 16.2% of total, noncontracted reimbursement for the practice.
1095 surgeon, a plastic surgeon, surgical oncologist, or otolaryngologist may also be better reimbursed for the operative care that they provide because of the stratified reimbursement scales for adult and pediatric procedures. For these reasons, some surgeons have ignored documentation and billing for nonoperative care. Only in specialties heavily weighted toward nonoperative management such as trauma/critical care and burn surgery have organized efforts been made to capture reimbursement for nonoperative services [4-7]. When nonoperative care is billed, it is essential that documentation be meticulous to maintain compliance with regulations and avoid fraud charges. To make the process of recording charges more efficient and less onerous, we have used an intranet-based, Filemakerk database to record charges on inpatients on a daily basis so that bills may be prepared on the day that a service is provided. This system is further facilitated by personal digital assistants (PDAs) that make the patient database portable and allow each surgeon to enter charge data for their patients as they visit them and download the data later. The reimbursement rates for nonoperative services (19%36%) were comparable to the average reimbursement rate for operative services of 31%. Furthermore, the time (about 10 minutes per typical H&P) and the transcription costs (covered by the hospital) required for documentation of nonoperative services were nominal. Although some pediatric surgeons focus mostly upon operative services, the yield from properly documented, nonoperative care can be substantial. In this era of diminished reimbursement for pediatric surgical procedures, aggressive documentation and billing for nonoperative care can help to recoup some of the money that had once been more available for salaries and academic activities. In our practice, we have concluded that documentation of nonoperative care is not only an integral part of resident supervision but is well-compensated relative to the amount of time that it consumes.
3. Discussion Despite a payer mix that was heavily weighted toward Medicaid, comprehensive documentation and billing for nonoperative services increased total, noncontracted reimbursement by almost 20% over what would have been obtained had only operative services been billed. The average payment for each E&M code (Table 1) was diminished by the inclusion of self-pay and capitated cases for which there was usually no reimbursement for the service provided. In addition, there was no payment for some services provided to patients covered by Medicaid or a commercial carrier when the care was contractually uncovered. Care was provided irrespective of insurance status. Pediatric surgeons with a high volume of trauma cases and emergency admissions and consultations provide a substantial amount of inpatient, nonoperative care. Although engaging in less nonoperative care than a pediatric
References [1] Seare JG. Medical documentation. Salt Lake City (Utah)7 Medicode; 1993. p. i - ii. [2] Driscoll P, editor. Ingenix coding lab: medical billing basics. 5th ed. Salt Lake City (Utah)7 Ingenix; 2002. p. 97. [3] Gordy TR, editor. Current procedural terminology: CPT 2004. Chicago (Ill)7 American Medical Association; 2004. p. 1 - 32. [4] Reed RL, Davis KA, Silver GM, et al. Reducing trauma payment denials with computerized collaborative billing. J Trauma 2003;55: 762 - 70. [5] Fakhry SM. Cilling, coding, and documentation in the critical care environment. Surg Clin North Am 2000;80:1067 - 83. [6] Heistein JB, Coffey RA, Buchele BA, et al. Development and initiation of computer generated documentation for burn patient care. J Burn Care Rehabil 2002;23:273 - 9. [7] Rogers FB, Osler T, Shackford SR, et al. Charges and reimbursement at a rural level 1 trauma center: a disparity between effort and reward among professionals. J Trauma 2003;54:9 - 15.