Healthcare Provider Feedback Improves Outpatient E/M Billing and Coding in Otolaryngology Clinics

Objective

Discrepancies in medical coding can negatively impact institutional revenue and result in accusations of medical fraud. The objective of the present study was to prospectively assess the utility of a dynamic feedback system for otolaryngology providers in improving the coding/billing accuracy of outpatient clinic encounters.

Methods

A billing audit of outpatient clinic visits was performed. Dynamic billing/coding feedback, consisting of a virtual lecture and targeted e-mails, was provided at distinct intervals by the institutional billing and coding department. χ ² was used for categorical data, and the Wilcoxon test was used to compare changes in accuracy over time.

Results

A total of 176 clinic encounters were reviewed. Prior to feedback, 60% of encounters were inaccurately billed by otolaryngology providers, requiring upcoding and representing a potential 35% work relative value unit (wRVU) loss of E/M generated productivity. After 1 year of feedback, providers significantly increased the accuracy of their billing from 40% to 70% (odds ratio [OR]: 3.55, p < .001, 95% confidence interval [CI]: 1.69, 7.29), with a corresponding decrease in potential wRVU loss from 35% to 10% (OR: 4.87, p < .001, 95% CI: 0.81, 10.51).

Discussion

Dynamic billing feedback significantly improved outpatient E/M coding among otolaryngology healthcare providers in this study.

Implications for Practice

This study demonstrates that educating providers on appropriate medical coding and billing policies, while providing dynamic, intermittent feedback, may improve billing accuracy, translating into appropriate charges and reimbursements for services provided.

Nasal endoscopy, room filtration, and aerosol concentrations during live outpatient encounters: a prospective, case-control study

Background

The coronavirus disease 2019 (COVID‐19) pandemic has highlighted safety concerns surrounding possible aerosol‐generating procedures, but comparative data on the smallest particles capable of transmitting this virus remain limited. We evaluated the effect of nasal endoscopy on aerosol concentration and the role of a high‐efficiency particulate air (HEPA) filter in reducing aerosol concentration.

Methods

Otolaryngology patients were prospectively enrolled in an outpatient, cross‐sectional study. Demographic information and clinic room characteristics were recorded. A scanning mobility particle sizer and GRIMM aerosol monitor measured aerosols 14.3 nm to 34 μm in diameter (i.e., particles smaller than those currently examined in the literature) during (1) nasal endoscopy (± debridement) and (2) no nasal endoscopy encounters. One‐way analysis of variance (ANOVA) and Student's t test were performed to compare aerosol concentrations and impact of HEPA filtration.

Results

Sixty‐two patients met inclusion criteria (25 nasal endoscopy without debridement; 18 nasal endoscopy with debridement; 19 no nasal endoscopy). There was no significant difference in age or gender across cohorts. Aerosol concentration in the nasal endoscopy cohort (± debridement) was not greater than the no nasal endoscopy cohort (p = 0.36; confidence interval [95% CI], −1.76 to 0.17 μg/m³; and p = 0.12; 95% CI, −0.11 to 2.14 μg/m³, respectively). Aerosol concentrations returned to baseline after 8.76 min without a HEPA filter versus 4.75 min with a HEPA filter (p = 0.001; 95% CI, 1.73–6.3 min).

Conclusion

Using advanced instrumentation and a comparative study design, aerosol concentration was shown to be no greater during nasal endoscopy versus no endoscopy encounters. HEPA filter utilization reduced aerosol concentrations significantly faster than no HEPA filter.

Radiofrequency Ablation vs Electrocautery Blinded Randomized Trial: Impact on Clinically Meaningful Outcomes

OBJECTIVE

To analyze patients' return to normal activity, pain scores, narcotic use, and adverse events after undergoing tonsillectomy or adenotonsillectomy with monopolar electrocautery or radiofrequency ablation.

STUDY DESIGN

Randomized double-blinded clinical trial based on prospective parallel design.

SETTING

Academic medical center and tertiary children's hospital between March 2018 and July 2019.

METHODS

Inclusion criteria included patients aged ≥3 years with surgical indication of recurrent tonsillitis or airway obstruction/sleep-disordered breathing. Patients were randomly assigned to monopolar electrocautery or radiofrequency ablation. Patients were blinded to treatment assignment. Survey questions answered via text or email were collected daily until postoperative day 15. The primary outcome was the patient's return to normal activity. Secondary outcomes included daily pain score, total amount of postoperative narcotic use, and adverse events.

RESULTS

Of the 236 patients who met inclusion criteria and were randomly assigned to radiofrequency ablation or monopolar electrocautery, 230 completed the study (radiofrequency ablation, n = 112; monopolar electrocautery, n = 118). There was no statistically significant difference between the groups in the number of days for return to normal activity (P = .89), daily pain scores over 15 postoperative days (P = .46), postoperative narcotic use (P = .61), or return to hospital for any reason (P = .60), including bleeding as an adverse event (P = .13).

CONCLUSIONS

As one of the largest randomized controlled trials examining instrumentation in tonsillectomy, our data do not show a difference between monopolar electrocautery and radiofrequency ablation with regard to return to normal activity, daily pain scores, total postoperative narcotic use, or adverse events.

Single-Blinded Prospective Implementation of a Preoperative Imaging Checklist for Endoscopic Sinus Surgery

Objective To determine if the introduction of a systematic preoperative sinus computed tomography (CT) checklist improves identification of critical anatomic variations in sinus anatomy among patients undergoing endoscopic sinus surgery. Study Design Single-blinded prospective cohort study. Setting Tertiary care hospital. Subjects and Methods Otolaryngology residents were asked to identify critical surgical sinus anatomy on preoperative CT scans before and after introduction of a systematic approach to reviewing sinus CT scans. The percentage of correctly identified structures was documented and compared with a 2-sample t test. Results A total of 57 scans were reviewed: 28 preimplementation and 29 postimplementation. Implementation of the sinus CT checklist improved identification of critical sinus anatomy from 24% to 84% correct ( P < .001). All residents, junior and senior, demonstrated significant improvement in identification of sinus anatomic variants, including those not directly included in the systematic review implemented. Conclusion The implementation of a preoperative endoscopic sinus surgery radiographic checklist improves identification of critical anatomic sinus variations in a training population.