Hospital-Wide Intervention in Billing and Coding to Capture Complexity of Care at an Academic Referral Center.

Abstract

Goal: Downcoding at nonprofit healthcare institutions can account for significant revenue losses that, in turn, can affect the amount and quality of care they provide. Using the inpatient medical note to assess the complexity of care, we wanted to quantify the visit coding distribution at the largest tertiary care center in West Virginia and to improve the documentation and coding if found to be below national benchmarks.

Methods: We measured the number of encounters and associated documentation of level 1, 2, and 3 visits among hospitalists. We compared our data to national benchmark data. We then implemented a multifaceted, multidisciplinary intervention to improve documentation and coding.

Principal findings: We found a significant average increase of level 3 admission history and physical visits of 76% ( p < .0001) and 112% ( p < .001) for subsequent encounters compared with baseline preintervention visit types. With team-based coding interventions in place, documentation accurately now reflects the complexity of care delivered. Based on Medicare reimbursement rates, this new accuracy has led to an increase in revenue of $233, 988.79 per 10,000 encounters.

Applications to practice: Provider knowledge of medical billing and coding guidelines is essential. In particular, large academic institutions typically operate on small margins, so even simple adjustments and quality improvement efforts in billing and coding can help immensely by accurately representing the amount and quality of medical services. An institution can markedly improve revenues by coding notes to reflect the true complexity of care that is delivered.