RVU ready? Preparing emergency medicine resident physicians in documentation for an incentive-based work environment

Best Practices in Medical Documentation: A Curricular Module

OBJECTIVE

To create and validate a checklist for high-quality documentation and pilot a multi-modal, immersive educational module across multiple institutions. We hypothesized that this module would improve knowledge, skills, and attitudes in medical documentation.

METHODS

Module design was grounded in an established curriculum design framework. We conducted the study across 12 pediatric critical care fellowship programs between September 2017 and January 2018. Workshops were allotted 90 minutes for completion. We utilized a pre-/post- study design to determine the workshop's impact. Changes in knowledge were assessed through pre and post testing. Changes in skills were evaluated with a validated checklist for inclusion of key documentation elements. Changes in attitudes were determined through learner self-assessment RESULTS: 83 of 138 eligible fellows (60%) started the module and 62 of 83 (75%) completed data sets for analysis. Immediate post-testing demonstrated modest statistically significant improvement in knowledge, skills, and attitudes. The workshop was easily disseminated and deployed CONCLUSIONS: This study demonstrates that a multi-modal educational intervention can lead to improvement in medical documentation knowledge, skills, and attitudes in a cohort of PCCM fellows and be easily disseminated for use by other specialties and types of clinicians.

It Pays to be Accurate: Improving Critical Care Documentation in a Pediatric Emergency Department

BACKGROUND

Clinician documentation is highly variable, and awareness of documentation requirements remains low despite post-training experience. At our hospital, critical care (CC) documentation was inconsistent. Our aim was to increase appropriate CC attestations from 51% to 90% for status asthmaticus, anaphylaxis, and diabetic ketoacidosis in the pediatric emergency department by December 2021.

METHODS

A physician team developed a key driver diagram. Retrospective baseline data using International Classification of Diseases, Ninth and Tenth Revision codes were obtained from January 2018 to September 2020, after which data were followed prospectively in consecutive groups of 20 encounters. Statistical process control charts were used to analyze data. Nelson rules were used to detect special cause variation. Primary outcome was the inclusion of appropriate CC attestations. Interventions included education, CC attestation templates, and provider feedback. We also tracked charges for the 3 diagnoses studied. Process measures included template use. Balancing measure was refusal of payment by insurers.

RESULTS

P-charts were used to analyze primary outcome and process measures. X-bar charts were used to analyze charges. Baseline data represented 706 encounters with 51% including CC documentation. Following clinician education and release of the CC template, special cause variation was detected, and centerline shifted to 88.1% (Fig 2). Average charges per encounter increased from $4527 to $5385. There was no reported refusal of payment.

CONCLUSIONS

We successfully achieved improvements in CC documentation in the 3 diagnoses of interest through education and process changes in documentation, leading over $1 million in new charges over the past 15 months.

Resident Perceptions of a Publicly Disclosed Daily Productivity Dashboard

Introduction

Following resident requests, we created a public metrics dashboard to inform residents of their daily productivity. Our goal was to iteratively improve the dashboard based on resident feedback and to measure the impact of reviewing aggregate data on self-perceived productivity.

Methods

A 10-question anonymous survey was completed by our postgraduate year 1–3 residents. Residents answered questions on the dashboard and rated their own productivity before and after reviewing aggregate peer-comparison data. Using the Wilcoxon signed-rank test we calculated summary statistics for survey questions and compared distributions of pre- and post-test, self-rated productivity scores.

Results

All 43 eligible residents completed the survey (response rate 100%). Thirteen (30%) residents “rarely” or “never” reviewed the dashboard. No respondents felt the dashboard measured their productivity or quality of care “extremely accurately” or “very accurately.” Seven (16%) residents felt “very” or “extremely pressured” to change their practice patterns based on the metrics provided, and 28 (65%) would have preferred private over public feedback. Fifteen residents (35%) changed their self-perceived rank after viewing peer-comparison data, although not significantly in a particular direction (z = 0.71, P = 0.48).

Conclusion

Residents did not view the presented metrics as reflective of their productivity or quality of care. Viewing the dashboard did not lead to statistically significant changes in resident self-perception of productivity. This finding highlights the need for expanding the resident conversation and education on metrics, given their frequent inclusion in attending physician workforce payment and incentive models.

The impact of removing global periods on pediatric surgeon reimbursement

PURPOSE

CMS has proposed removing postoperative care from the global periods for surgical procedures and instead requiring surgeons to bill for postoperative visits using evaluation & management (E&M) codes. This policy may alter reimbursement to pediatric surgeons.

METHODS

To assess the impact of this policy, NSQIP-pediatric data were used to calculate median LOS for high-volume procedures with 10 or 90 day global periods. We then merged these data with CMS physician work time and RVU files. A CMS LOS variable was created by counting the number of hospital-based E&M codes built into the global period based on the fact that if global periods are removed, surgeons may only bill one E&M code per postoperative day. We then compared the CMS and NSQIP LOS values.

RESULTS

The dataset included 201 CPT codes with NSQIP LOS estimates derived from a median of 137 operations. Twenty-nine procedures (14.4%) had higher, 24 (16.9%) had the same, and 138 (68.7%) had lower NSQIP median LOS than current CMS values. On average, NSQIP values were 40.0% (95% confidence interval [95CI] -50.0, -29.9%) lower than CMS values. Based on a daily average work RVU per postoperative E&M code of 1.09 (95% CI 1.05, 1.12), and $35.78 per RVU (2017 rate), surgeons in this sample would experience a cumulative annual reduction in reimbursement of approximately $3.4 M following the policy change.

CONCLUSIONS

Most pediatric surgical procedures have RVU valuations that include more hospital-based E&M codes than the current median number of postoperative days. Holding all else equal, the removal of global periods would therefore reduce reimbursement for pediatric surgeons. The downstream effects of this policy change, such as the impact on the quality of clinical care, are uncertain and warrant further investigation.

TYPE OF STUDY

Clinical research paper.

LEVEL OF EVIDENCE

Level II.

Compensation models in emergency medicine: An ethical perspective

There is considerable diversity in compensation models in the specialty of Emergency Medicine (EM). We review different compensation models and examine moral consequences possibly associated with the use of various models. The article will consider how different models may promote or undermine health care's quadruple aim of providing quality care, improving population health, reducing health care costs, and improving the work-life balance of health care professionals. It will also assess how different models may promote or undermine the basic bioethical principles of beneficence, non-maleficence, respect for autonomy, and justice.

Strategies for improving physician documentation in the emergency department: a systematic review

BACKGROUND

Physician chart documentation can facilitate patient care decisions, reduce treatment errors, and inform health system planning and resource allocation activities. Although accurate and complete patient chart data supports quality and continuity of patient care, physician documentation often varies in terms of timeliness, legibility, clarity and completeness. While many educational and other approaches have been implemented in hospital settings, the extent to which these interventions can improve the quality of documentation in emergency departments (EDs) is unknown.

METHODS

We conducted a systematic review to assess the effectiveness of approaches to improve ED physician documentation. Peer reviewed electronic databases, grey literature sources, and reference lists of included studies were searched to March 2015. Studies were included if they reported on outcomes associated with interventions designed to enhance the quality of physician documentation.

RESULTS

Nineteen studies were identified that report on the effectiveness of interventions to improve physician documentation in EDs. Interventions included audit/feedback, dictation, education, facilitation, reminders, templates, and multi-interventions. While ten studies found that audit/feedback, dictation, pharmacist facilitation, reminders, templates, and multi-pronged approaches did improve the quality of physician documentation across multiple outcome measures, the remaining nine studies reported mixed results.

CONCLUSIONS

Promising approaches to improving physician documentation in emergency department settings include audit/feedback, reminders, templates, and multi-pronged education interventions. Future research should focus on exploring the impact of implementing these interventions in EDs with and without emergency medical record systems (EMRs), and investigating the potential of emerging technologies, including EMR-based machine-learning, to promote improvements in the quality of ED documentation.

Impact of Early Educational Intervention on Coding for First-year Emergency Medicine Residents

OBJECTIVES

Coding of a medical visit is based on provider documentation in the medical record; the documentation should reflect the level of care that was provided. To maximize coding and subsequent billing, providers must complete various components of the record to best convey the complexity of the case. Little education is provided to resident physicians regarding appropriate documentation practices, and studies suggest a need for improved education in this area. The primary goal of this study is to determine if implementing an early educational intervention will improve billing and coding.

METHODS

This was a randomized, prospective controlled study in an academic Level I emergency department (ED). Interns without prior experience in billing and coding were eligible participants. Participants in the intervention group each received an interactive lecture on coding, evaluation and management (E/M) levels, and documentation macros, prior to their first ED rotation at the base hospital. A pocket card with E/M level requirements was given as a resource. Biweekly feedback was given to the residents to address any patterns of mistakes. The number of charts for each E/M level was collected from both groups, which were converted to relative value units (RVUs). A multivariate analysis using multivariate linear regressions controlling for age, sex of patient, admission rate, and month of encounter was used to statistically evaluate billing outcomes.

RESULTS

The mean RVUs per hour and encounter in the intervention group were, respectively, 3.52 and 3.84 while in the control group they were, respectively, 3.36 and 3.72 (p = 0.0112). Intervention group encounters had 27% greater odds (odds ratio = 1.27) of having a level 5 chart compared to the control group (p = 0.0025).

CONCLUSION

The focused longitudinal educational interventions resulted in improved billing performances, reflected by better documentation, in the intervention group versus the control group.

Is There Evidence for Systematic Upcoding of ASA Physical Status Coincident with Payer Incentives? A Regression Discontinuity Analysis of the National Anesthesia Clinical Outcomes Registry

BACKGROUND

Modifications in physician billing patterns have been shown to occur in response to payer incentives, but the phenomenon remains largely unexplored in billing for anesthesia services. Within the field of anesthesiology, Medicare's policy not to provide additional reimbursement for higher ASA physical status scores contrasts with the practices of most private payers, and this pattern of reimbursement introduces a change in billing incentives once patients attain Medicare eligibility. We hypothesized that, coincident with the onset of widespread Medicare eligibility at age 65 years, a discontinuity in reported ASA physical status scores would be observed after controlling for the underlying trend of increasing ASA physical status scores with age. This phenomenon would manifest as a pattern of upcoding of ASA physical status scores for patients younger than 65 years that would become less common in patients age 65 years and older.

METHODS

Using data on age, sex, ASA physical status scores, and type of surgery from the National Anesthesia Clinical Outcomes Registry, we used a quasi-experimental regression discontinuity design to analyze whether there was evidence for a discontinuity in reported ASA physical status scores occurring at age 65 years for the nondeferrable anesthesia services accompanying hip, femur, or lower leg fracture repair.

RESULTS

A total of 49,850 records were analyzed. In models designed to detect regression discontinuity at 65 years of age, neither the binary variable "age ≥ 65" nor the interaction term of age × age ≥ 65 was a statistically significant predictor of the outcome of ASA physical status score. The statistical inference was unchanged when ASA physical status scores were reclassified as a binary outcome (I-II vs III-V) and when different bandwidths around age 65 years were used. To test the validity of our study design for detecting regression discontinuity, simulations of the occurrence of deliberate upcoding of ASA physical status scores demonstrated the ability to detect deliberate upcoding occurring at rates exceeding 2% of eligible cases of patients younger than 65 years.

CONCLUSIONS

We found no evidence for a significant discontinuity in the pattern of ASA physical status scores coincident with Medicare eligibility at age 65 years for the nondeferrable conditions of hip, femur, or lower leg fracture repair. Our data do not support the presence of fraudulent ASA physical status scoring among National Anesthesia Clinical Outcomes Registry contributors. If deliberate upcoding of ASA physical status scores is present in our data, the behavior is either too rare or too insensitive to the removal of payer incentives at age 65 years to be evident in the present analysis.

Educating Emergency Medicine Residents in Emergency Department Administration and Operations: Needs and Current Practice

BACKGROUND

Emergency medicine (EM) residents are expected to develop competence in emergency department (ED) administration and operations.

OBJECTIVES

We assessed current needs and educational practices related to preparing EM residents for their role in ED operations, and explored whether there was an association between program characteristics and the presence of ED operations education in US EM residency programs.

METHODS

We conducted a cross-sectional needs assessment, using a web-based survey sent to all US EM residency programs to assess program characteristics, provision of ED operations-related lectures, availability of an ED administrative fellowship, and presence of a formal ED operations curriculum. Logistic regression was used to determine if any program characteristics were associated with the presence of lectures and a formal operations curriculum.

RESULTS

Of the 158 Accreditation Council for Graduate Medical Education-accredited EM programs, 117 (74%) responded. Of these, 109 (93%) respondents had at least 1 lecture on ED operational topics. Sixty programs (54%) measured resident productivity. Knowledge of Centers for Medicaid & Medicare Services reimbursement guidelines was significantly positively associated with presence of an ED operations curriculum (OR, 3.52, P  =  .009) and with lectures on patient satisfaction (OR, 3.99, P  =  .006). Measuring resident productivity was positively associated with having lectures on productivity (OR, 2.50, P  =  .02) and with ED throughput (OR, 2.32, P  =  .03). No 2 variables were simultaneously significant in the model.

CONCLUSIONS

Most EM programs had at least 1 lecture on ED operations topics. Roughly half of the programs measured resident productivity and half had a formal ED operations curriculum.

Mid-level Providers Working in a Low-acuity Area are More Productive than in a High-acuity Area

INTRODUCTION

Mid-level providers (MLP) are extensively used in staffing emergency departments (ED). We sought to compare the productivity of MLPs staffing a low-acuity and high-acuity area of a community ED.

METHODS

This is a retrospective review of MLP productivity at a single center 42,000-volume community ED from July 2009 to September 2010. MLPs staffed day shifts (8AM-6PM or 10AM-10PM) in high- and low-acuity sections of the ED. We used two-tailed T-test to compare patients/hour, relative value units (RVUs)/hour, and RVUs/patient between the 2 MLP groups.

RESULTS

We included 49 low-acuity and 55 high-acuity shifts in this study. During the study period, MLPs staffing low-acuity shifts treated a mean of 2.7 patients/hour (confidence interval [CI] +/- 0.23), while those staffing high-acuity shifts treated a mean of 1.56 patients/hour (CI +/- 0.14, p<0.0001). MLPs staffing low-acuity shifts generated a mean of 4.45 RVUs/hour (CI +/- 0.34) compared to 3.19 RVUs/hour (CI +/- 0.29) for those staffing high-acuity shifts (p<0.0001). MLPs staffing low-acuity shifts generated a mean of 1.68 RVUs/patient (CI +/- 0.06) while those staffing high-acuity shifts generated a mean RVUs/patient of 2.05 (CI +/- 0.09, p<0.0001).

CONCLUSION

MLPs staffing a low-acuity area treated more patients/hour and generated more RVUs/hour than when staffing a high-acuity area.

Resident awareness of documentation requirements and reimbursement: a multi-institutional survey

BACKGROUND

The current economic environment necessitates efforts to prevent avoidable losses in clinical revenue in academic cardiothoracic surgery programs. Inadequate documentation frequently results in delayed, denied, or reduced reimbursement. With the recent increase in integrated residency programs, documentation and compliance are becoming increasingly dependent on junior residents; however, their understanding of reimbursement and documentation guidelines is currently unknown.

METHODS

An electronically distributed, multi-institutional survey of 6 general and subspecialty surgery programs was conducted consisting of open-ended numeric estimation of Medicare reimbursement for various levels of patient encounters. Closed-ended questions were used to assess resident knowledge of documentation requirements, accompanied by self-estimated compliance with those requirements.

RESULTS

Thirty-seven percent (n = 106) of residents completed the survey. Most residents (77%) believe they play the primary role in documentation; however, knowledge of and compliance with higher level documentation practices range from 19% to 78% and 41% to 76%, respectively. On average, residents overestimate Medicare reimbursement of lower level encounters by as much as 77% and underestimate higher level encounters by as much as 38%. In many cases, the standard deviation of residents' estimates approaches the actual reimbursement value.

CONCLUSIONS

Residents have a limited knowledge of documentation requirements. Self-reported compliance, even when guidelines are known, is low. Estimation of financial reimbursement is extremely variable. Residents overestimate reimbursement of lower level encounters and underappreciate reimbursement at higher levels. Ensuring appropriate reimbursement for services rendered will require formal cardiothoracic resident education and ongoing quality control.

Accounting for the professional work of pathologists performing autopsies

CONTEXT

With an increasing trend toward fee-code-based methods of measuring the clinical professional productivity of pathologists, those pathologists whose clinical activities include the performance of autopsies have been disadvantaged by the lack of generally accepted workload equivalents for autopsy performance and supervision.

OBJECTIVE

To develop recommended benchmarks to account for this important and often overlooked professional activity.

DESIGN

Based on the professional experience of members of the Autopsy Committee of the College of American Pathologists, a survey of autopsy pathologists, and the limited additional material available in the literature, we developed recommended workload equivalents for the professional work associated with performing an autopsy, which we elected to express as multiples of established Current Procedural Terminology codes.

RESULTS

As represented in Table 3 , we recommend that the professional work associated with a full adult autopsy be equivalent to 5.5 × 88309-26. Additional professional credit of 1.5 × 88309-26 should be added for evaluation of the brain and for a detailed clinical-pathologic discussion. The corresponding value for a fetal/neonatal autopsy is 4.0 × 88309-26.

CONCLUSION

Although we recognize that autopsy practices vary significantly from institution to institution, it is hoped that our proposed guidelines will be a valuable starting point that individual practices can then adapt, taking into account the specifics of their practice environment.

Critical appraisal of emergency medicine educational research: the best publications of 2009

OBJECTIVES

The objective was to critically appraise and highlight methodologically superior medical education research specific to emergency medicine (EM) published in 2009.

METHODS

A search of the English language literature in 2009 querying Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE 1950 to Present, Web of Science, Education Resources Information Center (ERIC), and PsychInfo identified 36 EM studies that used hypothesis-testing or observational investigations of educational interventions. Six reviewers independently ranked all publications based on 10 criteria, including four related to methodology, that were chosen a priori to standardize evaluation by reviewers. This was a refinement of the methods used to appraise medical education published in 2008.

RESULTS

Seven studies met the standards as determined by the averaged rankings and are highlighted and summarized here. This year, 16 of 36 (44%) identified studies had funding, compared to 11 of 30 (36%) identified last year; five of seven (71%) highlighted publications were funded in 2009 compared to three of five (60%) highlighted in 2008. Use of technology in medical education was reported in 14 identified and four highlighted publications, with simulation being the most common technology studied. Five of the seven (71%) featured publications used a quasi-experimental or experimental design, one was observational, and one was qualitative. Practice management topics, including patient safety, efficiency, and revenue generation, were examined in seven reviewed studies.

CONCLUSIONS

Thirty-six medical education publications published in 2009 focusing on EM were identified. This critical appraisal reviews and highlights seven studies that met a priori quality indicators. Current trends are noted.