Improving Professional Billing Practices in a Pediatric Hospital Medicine Section.

Abstract

Background: Professional billing translates clinical complexity and physician work into Current Procedural Terminology (CPT) codes and work relative value units (wRVUs), which inform reimbursement and resource planning. Pediatric hospital medicine (PHM) involves complex, cognitive, and time-intensive care, making accurate documentation and code selection essential. Baseline data in our PHM section suggested underuse of appropriate codes, contributing to undercapture of physician work. We aimed to increase wRVUs per patient-day by 25% over 12 months.

Methods: We conducted a quality improvement initiative at an academic children's hospital from March 2024 to February 2025. Key drivers were billing knowledge, standardized documentation, workflows, and shared culture around billing. The primary outcome was wRVUs per patient-day; the secondary outcome was professional revenue. Process measures included targeted CPT code use. Balancing measures included coding, denial, or compliance concerns identified by the Revenue and Compliance team. Four Plan-Do-Study-Act cycles tested education, a billing guide, documentation tools, and billing data feedback. Statistical process control charts identified special cause variation.

Results: We analyzed 23 772 CPT codes. Mean wRVUs per patient-day increased from 1.9 to 2.5, a 32% increase sustained through December 2025. Professional revenue increased 31% during intervention and 40% during sustainability. Use of level 3 initial inpatient care codes increased from 11% to 58%, level 3 subsequent inpatient care codes from 12% to 54%, and prolonged discharge codes from 13% to 42%. Neonatal intensive care and critical care code use increased. No denial or compliance concerns were identified.

Conclusions: A section-wide quality improvement approach improved capture of physician work and professional revenue without billing or compliance concerns.