The financial advantages of medical scribes extend beyond increased visits.

Employing medical scribes can boost revenue for a practice, the authors show, well beyond being an opportunity to expand patient volume.

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

OBJECTIVE: Accurate documentation of patient care and acuity is essential to determine appropriate reimbursement as well as accuracy of key publicly reported quality metrics. We sought to investigate the impact of standardized note templates by inpatient advanced practice providers (APPs) on evaluation and management (E/M) charge capture, including outside of the global surgical package (GSP), and quality metrics including case mix index (CMI) and mortality index (MI). We hypothesized this clinical documentation initiative as well as improved coding of E/M services would result in increased reimbursement and quality metrics. METHODS: A documentation and coding initiative on the heart and vascular service line was initiated in 2016 with focus on improving inpatient E/M capture by APPs outside the GSP. Comprehensive training sessions and standardized documentation templates were created and implemented in the electronic medical record. Subsequent hospital care E/M (current procedural terminology codes 99231, 99232, 99233) from the years 2015 to 2017 were audited and analyzed for charge capture rates, collections, work relative value units (wRVUs), and billing complexity. Data were compared over time by standardizing CMS values and reimbursement rates. In addition, overall CMI and MI were calculated each year. RESULTS: One year following the documentation initiative, E/M charges on the vascular surgery service line increased by 78.5% with a corresponding increase in APP charges from 0.4% of billable E/M services to 70.4% when compared with pre-initiative data. The charge capture of E/M services among all inpatients rose from 21.4% to 37.9%. Additionally, reimbursement from CMS increased by 65% as total work relative value units generated from E/M services rose by 78.4% (797 to 1422). The MI decreased over the study period by 25.4%. Additionally, there was a corresponding 5.6% increase in the cohort CMI. Distribution of E/M encounter charges did not vary significantly. Meanwhile, the prevalence of 14 clinical comorbidities in our cohort as well as length of stay (P = .88) remained non-statistically different throughout the study period. CONCLUSIONS: Accurate clinical documentation of E/M care and ultimately inpatient acuity is critical in determining quality metrics that serve as important measures of overall hospital quality for CMS value-based payments and rankings. A system-based documentation initiative and expanded role of inpatient APPs on vascular surgery teams significantly improved charge capture and reimbursement outside the GSP as well as CMI and MI in a consistently complex patient population.

Cost of postoperative complications: How to avoid calculation errors.

Postoperative complications (PC) are a basic health outcome, but no surgery service in the world records and/or audits the PC associated with all the surgical procedures it performs. Most studies that have assessed the cost of PC suffer from poor quality and a lack of transparency and consistency. The payment system in place often rewards the volume of services provided rather than the quality of patients' clinical outcomes. Without a thorough registration of PC, the economic costs involved cannot be determined. An accurate, reliable appraisal would help identify areas for investment in order to reduce the incidence of PC, improve surgical results, and bring down the economic costs. This article describes how to quantify and classify PC using the Clavien-Dindo classification and the comprehensive complication index, discusses the perspectives from which economic evaluations are performed and the minimum postoperative follow-up established, and makes various recommendations. The availability of accurate and impartially audited data on PC will help reduce their incidence and bring down costs. Patients, the health authorities, and society as a whole are sure to benefit.

Speech recognition for clinical documentation from 1990 to 2018: a systematic review.

OBJECTIVE: The study sought to review recent literature regarding use of speech recognition (SR) technology for clinical documentation and to understand the impact of SR on document accuracy, provider efficiency, institutional cost, and more. MATERIALS AND METHODS: We searched 10 scientific and medical literature databases to find articles about clinician use of SR for documentation published between January 1, 1990, and October 15, 2018. We annotated included articles with their research topic(s), medical domain(s), and SR system(s) evaluated and analyzed the results. RESULTS: One hundred twenty-two articles were included. Forty-eight (39.3%) involved the radiology department exclusively and 10 (8.2%) involved emergency medicine; 10 (8.2%) mentioned multiple departments. Forty-eight (39.3%) articles studied productivity; 20 (16.4%) studied the effect of SR on documentation time, with mixed findings. Decreased turnaround time was reported in all 19 (15.6%) studies in which it was evaluated. Twenty-nine (23.8%) studies conducted error analyses, though various evaluation metrics were used. Reported percentage of documents with errors ranged from 4.8% to 71%; reported word error rates ranged from 7.4% to 38.7%. Seven (5.7%) studies assessed documentation-associated costs; 5 reported decreases and 2 reported increases. Many studies (44.3%) used products by Nuance Communications. Other vendors included IBM (9.0%) and Philips (6.6%); 7 (5.7%) used self-developed systems. CONCLUSION: Despite widespread use of SR for clinical documentation, research on this topic remains largely heterogeneous, often using different evaluation metrics with mixed findings. Further, that SR-assisted documentation has become increasingly common in clinical settings beyond radiology warrants further investigation of its use and effectiveness in these settings.

Finance and Time Use Implications of Team Documentation for Primary Care: A Microsimulation.

PURPOSE: To estimate the conditions under which team documentation-having a staff member enter history, place orders, and guide patients-would be financially viable at primary care practices, accounting for implementation costs. METHODS: We applied a validated microsimulation model of practice costs, revenues, and time use to data from 643 US primary care practices. We estimated critical threshold values for time saved from routine visits that would need to be redirected to new visits to avoid net revenue losses under: (1) a clerical documentation assistant (CDA) strategy where a scribe assists with recordkeeping; and (2) an advanced team-based care (ATBC) strategy where medical assistants perform history, documentation, counseling, and order entry. RESULTS: Using a fee-for-service model, we estimated that physicians would need to save 3.5 (95% CI, 3.3-3.7) minutes/encounter under a CDA strategy and 7.4 (95% CI, 4.3-10.5) minutes/encounter under an ATBC strategy to prevent net revenue losses. The redirected time would be expected to add 317 visit slots per year under CDA strategy, and 720 under ATBC strategy. Using a capitated payment model, physicians would need to empanel at least 127 (95% CI, 70-187) more patients under CDA and 227 (95% CI, 153-267) under ATBC to prevent revenue losses. Additional patient visits expected would be 279 (95% CI, 140-449) additional visit slots per year under CDA and 499 (95% CI, 454-641) under ATBC. CONCLUSIONS: Financial viability of team documentation under fee-for-service payment may require more physician time to be reallocated to patient encounters than under a capitated payment model.

Implementation of medical scribes in an academic urology practice: an analysis of productivity, revenue, and satisfaction.

PURPOSE: Pressure on physicians to increase productivity is rising in parallel with administrative tasks, regulations, and the use of electronic health records (EHRs). Physician extenders and clinical pathways are already in use to increase productivity and reduce costs and burnout, but other strategies are required. We evaluated whether implementation of medical scribes in an academic urology clinic would affect productivity, revenue, and patient/provider satisfaction. METHODS: Six academic urologists were assigned scribes for 1 clinic day per week for 3 months. Likert-type patient and provider surveys were developed to evaluate satisfaction with and without scribes. Matched clinic days in the year prior were used to evaluate changes in productivity and physician/hospital charges and revenue. RESULTS: After using scribes for 3 months, providers reported increased efficiency (p value = 0.03) and work satisfaction (p value = 0.03), while seeing a mean 2.15 more patients per session (+ 0.96 return visits, + 0.99 new patients, and + 0.22 procedures), contributing to an additional 2.6 wRVUs, $542 in physician charges, and $861 in hospital charges per clinic session. At a gross collection rate of 36%, actual combined revenue was + $506/session, representing a 26% increase in overall revenue. At a cost of $77/session, the net financial impact was + $429 per clinic session, resulting in a return-to-investment ratio greater than 6:1, while having no effect on patient satisfaction scores. Additionally, with scribes, clinic encounters were closed a mean 8.9 days earlier. CONCLUSIONS: Implementing medical scribes in academic urology practices may be useful in increasing productivity, revenue, and provider satisfaction, while maintaining high patient satisfaction.

Identification, Coding, and Reimbursement of Pediatric Malnutrition at an Urban Academic Medical Center.

BACKGROUND: The American Academy of Nutrition and Dietetics and the American Society of Parenteral and Enteral Nutrition released a pediatric malnutrition consensus statement in 2014 recommending the use of z-scores as indicators for identification and documentation of malnutrition. A shift in focus is needed on standardizing pediatric malnutrition language at institutions nationwide to make study data comparable. With this standardized language, establishment of institutional baselines for identification, coding, and reimbursement of pediatric malnutrition is crucial to measure process improvements. OBJECTIVES: The objectives of this study were to determine the prevalence of malnutrition among pediatric patients at an urban academic medical center, the frequency of malnutrition codes used, and the reimbursement impact of coding for malnutrition. METHODS: Electronic medical records of pediatric patients admitted from January 2013 to December 2015 were reviewed. Malnutrition was identified based on registered dietitian identification and z-score. Patients given a malnutrition-related International Classification of Diseases code upon discharge were identified. A reimbursement calculation was performed: the malnutrition-related International Classification of Diseases code was removed to determine the difference in reimbursement with vs without the code. RESULTS: Of the 1,532 admissions included in this study, 464 (30%) were identified as malnourished. A total of 152 (33%) malnourished patients were given a malnutrition-related secondary diagnosis. The calculation revealed that coding for malnutrition resulted in an additional $27,665.70 to the medical center. CONCLUSION: Malnutrition coding may have a significant financial impact and processes improvement efforts can be made to improve malnutrition coding.

The Hidden Cost of Regulation: The Administrative Cost of Reporting Serious Reportable Events.

BACKGROUND: More than half of the 50 states (27) and the District of Columbia require reporting of Serous Reportable Events (SREs). The goal is to hold providers accountable and improve patient safety, but there is little information about the administrative cost of this reporting requirement. This study was conducted to identify costs associated with investigating and reporting SREs. METHODS: This qualitative study used case study methods that included interviewing staff and review of data and documents to investigate each SRE occurring at one academic medical center during fiscal year 2013. A framework of tasks and a model to categorize costs was created. Time was summarized and costs were estimated for each SRE. RESULTS: The administrative cost to process 44 SREs was estimated at $353,291, an average cost of $8,029 per SRE, ranging $6,653 for an environmental-related SRE to $21,276 for a device-related SRE. Care management SREs occurred most frequently, costing an average $7,201 per SRE. Surgical SREs, the most expensive on average, cost $9,123 per SRE. Investigation of events accounted for 64.5% of total cost; public reporting, 17.2%; internal reporting, 10.2%; finance and administration, 6.0%; and 2.1%, other. Even with 26 states mandating reporting, the 17.2% incremental cost of public reporting is substantial. CONCLUSION: Policy makers should consider the opportunity costs of these resources, averaging $8,029 per SRE, when mandating reporting. The benefits of public reporting should be collectively reviewed to ensure that the incremental costs in this resource-constrained environment continue to improve patient safety and that trade-offs are acknowledged.

Trauma Surgeons Save Lives-Scribes Save Trauma Surgeons!

With the advent of the electronic medical record, the documentation burden of the trauma surgeon has become overwhelming. To help, our trauma division added scribes to the rounding team. We hypothesized that scribe utilization would improve our documentation efficiency and offer a financial benefit to the institution. A review of trauma surgeon documentation and billing was performed at a Level I trauma center over two time periods: January to May 2014 (no scribes) and January to May 2015 (scribes). The number of notes written by trauma surgeons was obtained, as were documentation charges. Documentation efficiency was determined by noting both the hour of the day in which inpatient progress notes were written and the number of notes written after patient discharge. In the 2014 period, a total of 9726 notes were written by trauma attendings. In the 2015 period, 10,933 were written. Despite having 407 fewer trauma patient-days in the 2015 period, the group wrote 343 notes/week versus 298 notes/week (P = 0.008). More inpatient progress notes were written earlier in the working day and fewer were written in the evening. Fewer notes were written after patient discharge (12.7 vs 8.4%). A total of 1,664 hours of scribe time were used over the 5-month period, generating an expense of $32,787. The additional notes generated by scribes resulted in $191,394 in charges. Conservatively, assuming a 20 per cent charge reimbursement, the cost of the scribes was covered. The addition of scribes to the daily trauma rounding team improved note efficiency and increased charge capture at our center.

Advance Care Planning in an Accountable Care Organization Is Associated with Increased Advanced Directive Documentation and Decreased Costs.

BACKGROUND: Advance care planning (ACP) documents patient wishes and increases awareness of palliative care options. OBJECTIVE: To study the association of outpatient ACP with advanced directive documentation, utilization, and costs of care. DESIGN: This was a case-control study of cases with ACP who died matched 1:1 with controls. We used 12 months of data pre-ACP/prematch and predeath. We compared rates of documentation with logit model regression and conducted a difference-in-difference analysis using generalized linear models for utilization and costs. SETTING/SUBJECTS: Medicare beneficiaries attributed to a large rural-suburban-small metro multisite accountable care organization from January 2013 to April 2016, with cross reference to ACP facilitator logs to find cases. MEASUREMENTS: The presence of advance directive forms was verified by chart review. Cost analysis included all utilization and costs billed to Medicare. RESULTS: We matched 325 cases and 325 controls (51.1% female and 48.9% male, mean age 81). 320/325 (98.5%) ACP versus 243/325 (74.8%) of controls had a Healthcare Power of Attorney (odds ratio [OR] 21.6, 95% CI 8.6-54.1) and 172/325(52.9%) ACP versus 145/325 (44.6%) controls had Practitioner Orders for Life Sustaining Treatment (OR 1.40, 95% CI 1.02-1.90) post-ACP/postmatch. Adjusted results showed ACP cases had fewer inpatient admissions (-0.37 admissions, 95% CI -0.66 to -0.08), and inpatient days (-3.66 days, 95% CI -6.23 to -1.09), with no differences in hospice, hospice days, skilled nursing facility use, home health use, 30-day readmissions, or emergency department visits. Adjusted costs were $9,500 lower in the ACP group (95% CI -$16,207 to -$2,793). CONCLUSIONS: ACP increases documentation and was associated with a reduction in overall costs driven primarily by a reduction in inpatient utilization. Our data set was limited by small numbers of minorities and cancer patients.

Point-of-Care Ultrasound Work Flow Innovation: Impact on Documentation and Billing.

OBJECTIVES: To evaluate the impact that an innovative automated ultrasound (US) work flow, which allows for bedside performance of examination documentation and order placement, has on point-of-care US billing compared to ordering US examinations through an electronic medical record. METHODS: We conducted a retrospective review of point-of-care US billing data (March 2014-February 2016) for adult and pediatric emergency departments with an emergency medicine residency and a US fellowship. An innovative work flow with the ability to automate US billing and selectively transfer the images and reports for patient care examinations to an electronic medical record and picture archiving and communication system using the QPath US work flow solution (Telexy Healthcare, Maple Ridge, British Columbia, Canada) was implemented. The total number of examinations billed and percent increase in technical and professional revenue, excluding examinations performed by US fellows, before and after implementation of the automated work flow innovation were determined. RESULTS: After implementation of our automated US work flow process, the number of patient care US examinations billed increased significantly due to completing documentation and immediate billing determination at the bedside. The increase in percent billing relative to total examinations was noted in both technical (32% to 61%; P < .0001) and professional (37% to 65%; P < .0001) billing components. In addition, there was a net increase in technical and professional fee revenue to 96% and 78%, respectively. CONCLUSIONS: The implementation of an innovative automated work flow to include bedside point-of-care US documentation, order placement, and the automated transfer of images and reports led to a significant increase in US billing revenue, documentation, and compliance.

Implications of Clinical Documentation (In)Accuracy: A Pilot Study Among General Surgery Residents.

Accurate and reliable medical records are necessary for assessing, improving, and reimbursing healthcare services. Clear and concise physician documentation is essential to assuring accurate and reliable medical records. Yet, prior literature reveals surgery residents do not receive adequate, beneficial education on medical record documentation and coding. This is concerning because the evaluation of and reimbursement for healthcare service delivery relies on the physician's ability to produce appropriate medical records, which then get translated into billable codes. This pilot study suggests hospitals may incur significant financial loss in revenue due to inaccurate clinical documentation by residents. Thus, educational training for medical residents in the area of clinical documentation and hospital-specific coding practices may prove financially advantageous.

Impact of Scribes on Billed Relative Value Units in an Academic Emergency Department.

BACKGROUND: Scribe use throughout health care is becoming more common. There is limited peer-reviewed literature supporting this emerging role in health care despite rapid uptake of the role. OBJECTIVES: Our study assesses impact of scribes on relative value units (RVUs) in adult and pediatric emergency departments (EDs). METHODS: A prospective cohort study was developed in a tertiary academic ED. Charts were coded by an external billing and coding company, then returned and mapped by International Classification of Diseases, 9th revision diagnostic codes. After training by a staff member with significant experience in implementing scribe programs, scribes provided 1-to-1 support to a provider as staffing allowed. Comparisons were made between scribed and nonscribed visits. RESULTS: There were 49,389 patient visits during the study period (39,926 adult [80.84%] and 9463 pediatric [19.16%] visits), of which 7865 (15.9%) were scribed. For adults, scribed visits produced 0.20 additional RVUs per patient (p < 0.001). Scribes generated additional RVUs in Emergency Severity Index (ESI) 2 (p < 0.001) and 3 (p < 0.001) patients. There were variable effects of scribes on RVUs by diagnostic codes. For pediatric patients, scribed encounters generated 0.08 fewer RVUs per patient (p = 0.007). ESI score had no effect on RVUs. The impact of scribes on pediatric diagnostic groupings was inconsistent. CONCLUSIONS: Scribes had a positive impact on RVUs in adult but not pediatric patients. Among adults, scribes led to higher RVUs in ESI 2 and 3 but not 4 and 5 patients, perhaps suggesting a limitation to improve revenue capture on lower-acuity patients.

A multidisciplinary approach to vascular surgery procedure coding improves coding accuracy, work relative value unit assignment, and reimbursement.

BACKGROUND: Vascular surgery procedural reimbursement depends on accurate procedural coding and documentation. Despite the critical importance of correct coding, there has been a paucity of research focused on the effect of direct physician involvement. We hypothesize that direct physician involvement in procedural coding will lead to improved coding accuracy, increased work relative value unit (wRVU) assignment, and increased physician reimbursement. METHODS: This prospective observational cohort study evaluated procedural coding accuracy of fistulograms at an academic medical institution (January-June 2014). All fistulograms were coded by institutional coders (traditional coding) and by a single vascular surgeon whose codes were verified by two institution coders (multidisciplinary coding). The coding methods were compared, and differences were translated into revenue and wRVUs using the Medicare Physician Fee Schedule. Comparison between traditional and multidisciplinary coding was performed for three discrete study periods: baseline (period 1), after a coding education session for physicians and coders (period 2), and after a coding education session with implementation of an operative dictation template (period 3). The accuracy of surgeon operative dictations during each study period was also assessed. An external validation at a second academic institution was performed during period 1 to assess and compare coding accuracy. RESULTS: During period 1, traditional coding resulted in a 4.4% (P = .004) loss in reimbursement and a 5.4% (P = .01) loss in wRVUs compared with multidisciplinary coding. During period 2, no significant difference was found between traditional and multidisciplinary coding in reimbursement (1.3% loss; P = .24) or wRVUs (1.8% loss; P = .20). During period 3, traditional coding yielded a higher overall reimbursement (1.3% gain; P = .26) than multidisciplinary coding. This increase, however, was due to errors by institution coders, with six inappropriately used codes resulting in a higher overall reimbursement that was subsequently corrected. Assessment of physician documentation showed improvement, with decreased documentation errors at each period (11% vs 3.1% vs 0.6%; P = .02). Overall, between period 1 and period 3, multidisciplinary coding resulted in a significant increase in additional reimbursement ($17.63 per procedure; P = .004) and wRVUs (0.50 per procedure; P = .01). External validation at a second academic institution was performed to assess coding accuracy during period 1. Similar to institution 1, traditional coding revealed an 11% loss in reimbursement ($13,178 vs $14,630; P = .007) and a 12% loss in wRVU (293 vs 329; P = .01) compared with multidisciplinary coding. CONCLUSIONS: Physician involvement in the coding of endovascular procedures leads to improved procedural coding accuracy, increased wRVU assignments, and increased physician reimbursement.

The painful truth: The documentation burden of a trauma surgeon.

BACKGROUND: Implementation of the electronic medical record (EMR) has introduced several unintended consequences, including increased documentation demands. The purpose of this study was to define the EMR documentation burden and its economic impact at a busy regional Level I trauma center, comparing attending trauma surgeons (TSs) with orthopedic surgeons (OSs), and neurosurgeons (NSs). METHODS: The EMR was queried to determine the number of attending documentation entries during 2014 for TS, OS, and NS. The eight TSs were then surveyed to estimate the time it took to write each note type, and this was used to calculate the total time needed for documentation. The hospital financial database was queried for 2014 hospital charges and work relative value units (WRVUs) for TSs, OSs, and NSs to generate a comparison. The charges and WRVUs were broken down into those generated from nonprocedural documentation and procedures. RESULTS: During 2014, there were 5,864 trauma activations with 3,111 patient admissions. The attending TSs wrote a total of 26,455 documentation entries. Of these notes, 92% were from inpatients, and 74% were progress notes. Documentation time estimates for TSs demonstrated that it took 1,760.5 hours or 73.3 twenty-four-hour days to complete these 26,455 notes. Financial data revealed that 44% of the TS charges were directly related to nonprocedural documentation, compared with 14% for OSs and 7% for NSs. Evaluation of WRVUs demonstrated that 55% of the TS WRVUs were directly related to nonprocedural documentation, compared with 28% for OSs and 19% for NSs. CONCLUSION: The EMR has introduced a significant documentation burden to the busy TSs. This documentation burden is critical for defining hospital charges and WRVUs, and it differs from that of OSs and NSs. Workflow changes, such as the introduction of scribes, may lessen the documentation burden and improve hospital charges and WRVUs of the TSs.

[Documentation Time and Effort and Associated Resources for Patients with Primary Breast Cancer from Diagnosis to End of Follow-Up - Results of a Multicentre Validation]. / Dokumentationsaufwand und verbundene Ressourcen bei Patientinnen mit einem primären Mammakarzinom - von der Primärdiagnose bis zur Abschluss der Nachsorge - Ergebnisse der multizentrischen Erhebung.

INTRODUCTION: Tumour documentation is essential for quality assurance of oncological therapies and as a source of reliable information about the in- and outpatient care. The documentation effort and the associated resource consumption were analysed for the example of breast cancer. MATERIAL AND METHODS: The different steps in the care of patients with primary breast cancer in a standardised disease situation were defined from initial diagnosis to the end of the follow-up. After the pilot phase, a multicentre validation (n=7 centres) was performed with the support of the Federal Ministry of Health. The documentation time points were horizontally collected and analysed with regard to amount, duration and personnel expenses. RESULTS: 57% of the documentation costs are caused by the physicians. Regarding the different centres, documentation costs were calculated between € 352.82 and € 1 084.08 per patient from diagnosis to completion of aftercare. Non-certified centres had a reduced documentation effort and thus lower costs. CONCLUSIONS: The results demonstrate the need for a reduction of the documentation effort - particularly for physicians - the most expensive profession in the health system. A quality improvement is expected from the certification with its special requirements. In this context, there is a justified demand for an adequate remuneration of the documentation effort for certified centres. Furthermore, it is necessary to reduce the number of variables for quality assurance and to define them centrally. A comprehensive multi-disciplinary documentation should be achieved. Investments in a single data set and interface enhancements of existing documentation systems should be realised.