Improving clinical documentation of evaluation and management care and patient acuity improves reimbursement as well as quality metrics

Empowering Health Care Providers: A Collaborative Approach to Enhance Financial Performance and Productivity in Clinical Practice

Background

The combination of inadequate financial training, limited benchmarks, and mindset contribute to many physicians prioritizing revenue below quality, outcomes, and safety. This creates a challenge as hospital administrators aim to motivate clinicians to improve RVU generation and increase revenue.

Recent Findings

Creating physician/administrator teams that defines and explores the gap between observed and expected financial performance in parallel with appreciating the physician's practice preferences can create new opportunities for billing. The proposed 3 phase approach emphasizes nonjudgmental communication, education and partnership. The most common and effective opportunities for improvement include billing optimization, scheduling and system infrastructure modifications.

Implications for Practice

As reimbursement decrease, balancing revenue generation with physician satisfaction has become paramount. Promoting data drive bidirectional communication can lead to identifying previously unrecognized billing opportunities where change is driven by providers rather than by 1-dimensional institutional goals.

The Application of Dental Fluoride Varnish in Children: A Low Cost, High-Value Implementation Aided by Passive Clinical Decision Support

BACKGROUND

Fluoride is vital in the prevention of dental caries in children. In 2014, the U.S. Preventive Services Task Force deemed fluoride varnish a recommended preventive service (grade B). Electronic health record-based clinical decision support (CDS) tools have shown variable ability to alter physicians' ordering behaviors.

OBJECTIVES

This study aimed to increase the application of fluoride varnish in children while analyzing the effect of two passive CDS tools-an order set and a note template.

METHODS

Data on outpatient pediatric visits over an 18-month period before and after CDS implementation (October 15, 2020-April 15, 2022) were queried, while trends in application rate of fluoride were examined. We constructed a multiple logistic regression model with a primary outcome of whether a patient received fluoride at his/her visit. The primary predictor was a "phase" variable representing the CDS implemented. Physician interaction with CDS as well as the financial effects of the resulting service use were also examined.

RESULTS

There were 3,049 well-child visits of children aged 12 months to 5 years. The addition of a fluoride order to a "Well Child Check" order set led to a 10.6% increase in ordering over physician education alone (25.4 vs. 14.8%, p = 0.001), while the insertion of fluoride-specific text to drop-down lists in clinical notes led to a 6.2% increase (31.5 vs. 25.4%, p = 0.005). Whether a patient received topical fluoride was positively associated with order set implementation (odds ratio [OR] = 5.87, 95% confidence interval [CI]: 4.20-8.21) and fluoride-specific drop-down lists (OR = 7.81, 95% CI: 5.41-11.28). Female providers were more likely to use order sets when ordering fluoride (56.2 vs. 40.9% for males, p ≤ 0.0001). Added revenue totaled $15,084.

CONCLUSION

The targeted use of order sets and note templates was positively associated with the ordering of topical fluoride by physicians.

Original Research: Practice Variations in Documenting Neurologic Examinations in Non-Neuroscience ICUs

BACKGROUND

In critical care units, the neurologic examination (neuro exam) is used to detect changes in neurologic function. Serial neuro exams are a hallmark of monitoring in neuroscience ICUs. But less is known about neuro exams that are performed in non-neuroscience ICUs. This knowledge gap likely contributes to the insufficient guidance on what constitutes an adequate neuro exam for patients admitted to a non-neuroscience ICU.

PURPOSE

The study purpose was to explore existing practices for documenting neuro exams in ICUs that don't routinely admit patients with a primary neurologic injury.

METHODS

A single-center, prospective, observational study examined documented neuro exams performed in medical, surgical, and cardiovascular ICUs. A comprehensive neuro exam assesses seven domains that can be divided into 20 components. In this study, each component was scored as present (documentation was found) or absent (documentation was not found); a domain was scored as present if one or more of its components had been documented.

RESULTS

There were 1,482 assessments documented on 120 patients over a one-week period. A majority of patients were male (56%), White (71%), non-Hispanic (77%), and over 60 years of age (50%). Overall, assessments of the domains of consciousness, injury severity, and cranial nerve function were documented 80% of the time or more. Assessments of the domains of pain, motor function, and sensory function were documented less than 60% of the time, and that of speech less than 5% of the time. Statistically significant differences in documentation were found between the medical, surgical, and cardiovascular ICUs for the domains of speech, cranial nerve function, and pain. There were no significant differences in documentation frequency between day and night shift nurses. Documentation practices were significantly different for RNs versus providers.

CONCLUSIONS

Our findings show that the frequency and specific components of neuro exam documentation vary significantly across nurses, providers, and ICUs. These findings are relevant for nurses and providers and may help to improve guidance for neurologic assessment of patients in non-neurologic ICUs. Further studies exploring variance in documentation practices and their implications for courses of treatment and patient outcomes are warranted.

Insurance Authorization Barriers in Patients Undergoing Cytoreductive Surgery and HIPEC

BACKGROUND

Indications for cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) exist across multiple histologies, but little data exist on the impact of insurance authorization on access to these therapies. Given the evolving role of CRS/HIPEC, we sought to characterize insurance approval and delays in patients undergoing these therapies.

PATIENTS AND METHODS

A retrospective review was performed at a high-volume tertiary center of patients who received CRS/HIPEC from 2017 to 2021. Collected data included patient demographics, tumor histologic characteristics, insurance type, approval/denial history, and time to prior authorization approval. Descriptive statistics were performed.

RESULTS

In total, 367 patients received CRS/HIPEC during the study period. They had a median age of 59 (IQR 49-67) years, 35% were male, and 76% were white. Of the patients requiring prior authorization, 14 of 104 (13%) patients were denied prior authorization and required appeal. Median time between authorization request and approval was 33 (IQR 28-36) days. These cases generated 410 insurance authorization requests, 94 (23%) of which were not initially approved and required appeal. The rate of upfront denial was 21.1% in patients with public insurance compared with 23.4% in patients with private insurance. Gastric cancer was the most common histology among denied cases (55%), followed by colorectal, appendiceal, and gynecologic malignancies.

CONCLUSIONS

Despite the broadening indications for and data supporting CRS/HIPEC, a significant proportion of patients still face hurdles in attaining insurance approval and coverage for these therapies. Addressing barriers to insurance approval is imperative to decrease therapeutic delay and improve access to data-driven care.