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Objectives: The emergency medicine (EM) job market is increasingly focused on incentive-based reimbursement, which is largely based on relative value units (RVUs) and is directly related to documentation of patient care. Previous studies have shown a need to improve resident education in documentation. The authors created a focused educational intervention on billing and documentation practices to meet this identified need. The hypothesis of this study was that this educational intervention would result in an increase in RVUs generated by EM resident physicians and the average amount billed per patient.
Methods: The authors used a quasi-experimental study design. An educational intervention included a 1-hour lecture on documentation and billing, biweekly newsletters, and case-specific feedback from the billing department for EM resident physicians. RVUs and charges generated per patient were recorded for all second- and third-year resident physicians for a 3-month period prior to the educational intervention and for a 3-month period following the intervention. Pre- and postintervention data were compared using Student’s t-test and repeated-measures analysis of variance, as appropriate.
Results: The evaluation and management (E/M) chart levels billed during each phase of the study were significantly different (p < 0.0001). The total number of RVUs generated per hour increased from 3.17 in the first phase to 3.71 in the second phase (p = 0.0001). During the initial 3-month phase, the average amount billed per patient seen by a second- or third-year resident was $282.82, which increased to $301.94 in the second phase (p = 0.0004).
Conclusions: The educational intervention positively affected resident documentation resulting in greater RVUs/hour and greater billing performance in the study emergency department (ED).
Since its creation by the Health Care Financing Administration (HCFA, now the Centers for Medicare and Medicaid Services [CMS]) in 1992, the relative value unit (RVU) has become an important measurement tool for the work performed by physicians. Each emergency physician (EP) should have a thorough understanding of this unit to appreciate its use in making comparisons between physicians in regards to work output, billing for physician services, and determining and justifying staffing needs. However, the RVU has most recently gained attention for its relation to physician reimbursement. A Schumacher Group survey of emergency department (ED) administrators found that many EPs are not well prepared for incentive-based salaries.1 To be compensated well in this setting, resident physicians must understand RVUs and proper documentation.
Relative value units were developed by HCFA to construct a fee schedule for reimbursement of physician services. The total RVU has three components: the work RVUs for physician time and effort, practice RVUs to cover equipment and supplies, and malpractice RVUs for malpractice premiums. RVUs are given for both the documented procedures performed and the evaluation and management (E/M) level of the chart. The E/M level of a chart is determined by set criteria, key among them being history, physical examination, and medical decision-making. The more detailed the history and physical examination, and the more complex the decision-making, the higher the E/M level of chart, but only if it is documented accordingly. Downcoding results when a patient encounter warrants a higher level than is billed due to missing elements of history, physical examination, or medical decision-making in the physician’s documentation.
Although the Accreditation Council on Graduate Medical Education (ACGME) recommends that educational activities involving billing and coding be included as a part of the core competency of professionalism,2 studies have shown that resident physicians do not feel comfortable with the amount of education they are receiving in the areas of billing and coding.3,4 An abstract presented at the 2006 American College of Emergency Physicians Research Forum found that resident charts are more frequently downcoded than attending physician charts.5
Educational interventions have previously been tried for emergency medicine (EM) resident physicians involving a financial incentive for complete documentation,6 as well as for internal medicine resident physicians by implementing a template history and physical form,7 both of which resulted in improvements in the documented level of care by resident physicians. The authors previously completed an unpublished study at our academic facility and identified a need to improve EM resident physician education on billing and documentation. In that study, a survey given to both EM residents and attending physicians regarding billing and documentation practices found that 91% of resident physicians and 95% of attending physicians feel that this knowledge will be an important part of their future jobs. Eighty-two percent of resident physicians reported wanting more education in this area. An educational intervention would both comply with the ACGME core competency requirement and better prepare our resident physician graduates for incentive-based reimbursement.
We created a focused educational intervention on billing and documentation practices to meet this identified need. The intervention included focused education in complete documentation of charts and the appropriate use of E/M codes. It also provided case-specific feedback and involved identifying and creating templates to document billable EP procedures. The hypothesis of this study was that this educational intervention would result in an increase in RVUs generated by EM resident physicians and the average amount billed per patient.
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The lecture was given during a mandatory lecture session; however, only 75% of the residents included in the study were present for this lecture. Handouts from the lecture and the biweekly newsletters were provided to all residents.
Using a quasi-experimental design limits the study due to the lack of a control group. Introducing a control group would have resulted in smaller study numbers and presented the challenge of preventing those residents from viewing the newsletters or hearing about the lecture. Had we included a control group, we would have been able to control for the natural progression of resident physicians over the 6-month study period as they familiarized themselves with procedures and documentation. However, we attempted to limit this by excluding interns from the study, as it was felt that interns experience a more rapid improvement in many areas of ED practice, from documentation to patients seen per hour.
The increase in patients seen per hour by the second- and third-year resident physicians was statistically significant between the two study periods. However, the difference between 1.08 patients/hour and 1.17 patients/hour is just 1/10 of a patient/hour and may not be clinically significant. Also, the acuity levels of patients, and thus those qualifying for higher E/M codes and those requiring procedures, may have been different between the two time periods despite the unchanged admission level.
Although we did not openly disclose that resident documentation and RVU generation was being studied during either phase, it is possible that residents may have realized this was occurring and therefore put forth more effort in their documentation during Phase 2, resulting in an increase in chart level and RVUs generated.
We did not keep track of hours spent finishing charts after a scheduled shift for either study period. The improved documentation may have come at the cost of increased hours in the department, effectively “off the clock.” This study is also limited in that it was confined to one academic ED, and it is likely that each ED will have different areas of strength and weakness with regards to billing and documentation practices.
The study was performed using a single commercial documentation program and therefore might not be applicable to settings using a different program, dictation, or written documentation. Future areas of research could include evaluating resident physician documentation and billing after graduation for those resident physicians receiving the educational intervention and for those resident physicians who graduated prior to the study. Future studies could also evaluate whether ongoing education and feedback is required to maintain this change or if a one-time intervention is sufficient to affect long-term change.