Optimizing Advanced Practitioner Charge Capture in High-Acuity Surgical Intensive Care Units

Objective  To determine the impact of standardized critical care documentation tools on charge capture by intensive care unit (ICU) advanced practitioners (APs).

Design  Prospective charge capture analysis of AP critical care charges (Current Procedural Terminology codes 99291 or 99292).

Setting  Neurosurgical, general surgical, and cardiothoracic ICUs in a level I, 800-bed hospital. The AP provider to patient ratio was 1:6, with 24-hour surgical intensivist oversight.

Participants  Advanced practice registered nurses and physician assistants in the ICU.

Interventions  Standardized templates were developed to simplify documentation and optimize billing of critical care. All APs participated in comprehensive educational sessions on billing compliance and documentation.

Main Outcome Measures  Charge capture was collected for 3 years, and comparisons were made between the first quarter before (fiscal year [FY] 2008), during (FY 2009) and after (FY 2010) implementation. The number of ICU patient-days, length of stay, and of beds was collected.

Results  During the implementation/education phase (FY 2009), there were no differences in charge capture compared with FY 2008. Each unit demonstrated an increase in charge capture after implementation, and an overall increase of 48% for all 3 ICUs was seen. The number of admissions and length of stay were not statistically different. The total number of ICU beds increased from 42 to 45 during the evaluation period. The salary offset for APs increased from 62% to 80%.

Conclusions  Advanced practitioners represent an important component of the critical care services provided to patients in high-acuity surgical ICUs. Standardized critical care documentation and comprehensive education on evaluation and management guidelines significantly increased charge capture.

Between 2000 and 2005, the number of critical care beds in the United States increased by 6.5%, accounting for greater than 13% of hospital costs, 4% of national health expenditures, and 0.6% of the gross domestic product.¹ As capacity and health care costs increase, hospitals must identify methods to enhance revenue generation, ensure appropriate and adequate clinical coverage, and maintain compliance with reimbursement guidelines through adherence to proper coding of evaluation and management (E&M) services. These codes determine reimbursement according to the complexity of the patient evaluation and the type of service delivered. For critical care providers, these services are based on time and typically reflect the aggregate time that a provider cares for a critically ill patient during a workday.

Compliance with the Centers for Medicare and Medicaid Services (CMS) regulations for documentation is essential for institutions to avoid penalties and repayments due to lack of agreement between documentation of care provided and charges submitted for Medicare/Medicaid patients. Standardized template forms with compliance guidelines have been used to enhance compliance and increase billable income by appropriately representing the care provided.^2,3 Templates permit reproducible and consistent documentation by health care providers at multiple levels and can be easily modified to fit a specific patient population or service area.

Although compliance with CMS guidelines and the knowledge of specific E&M coding details is essential to clinician documentation, many training programs struggle with how to incorporate this skill set in a consistent manner. Moreover, the limitation of resident work hours imposed by the Accreditation Council for Graduate Medical Education has driven many hospitals to employ increasing numbers of physician extenders (advanced practice registered nurses and physician assistants, ie, advanced practitioners [APs]) to maintain workflow, ensure patient safety, and maintain high-quality patient care.

As critical care needs and capacity increase, the use of APs in intensive care unit (ICU) staffing models has also increased, although their role in the critical care setting has not been extensively investigated. Physician extenders, as direct providers of patient care, are able to generate revenue from their E&M of patients and may serve as an important resource for revenue enhancement. The purpose of this study was to determine the impact of standardized critical care documentation tools and comprehensive E&M education on charge capture by APs in the surgical ICUs at a large tertiary referral hospital.

We performed a prospective, charge capture analysis of all critical care bills with the Current Procedural Terminology (CPT) codes 99291 or 99292 that were submitted by the APs providing care in the cardiothoracic (CTICU), neurosurgical (NICU), and general surgical (GSICU) ICUs at Hartford Hospital.⁴ Hartford Hospital, the largest teaching affiliate of the University of Connecticut Integrated General Surgery Residency Program, is a level I trauma center with 800 beds, 42 of which constitute the surgical critical care service.

In the NICU and CTICU, 24-hour coverage is provided throughout the week by the APs (provider to patient ratio, 1:6), with additional 24-hour oversight by a surgical intensivist. In the GSICU, care is provided by residents, fellows, and APs, also with 24-hour oversight by a surgical intensivist. Throughout fiscal year (FY) 2009, all APs participated in comprehensive educational sessions that focused on E&M coding, documentation, and billing compliance. Providers were given feedback from supervising attending physicians as needed regarding documentation practices. Daily audits were performed by the director of critical care, and random audits were conducted by the Office for Professional Services of Hartford Hospital to assess compliance with CMS guidelines. Net revenue for critical care bills submitted with the CPT codes 99291 or 99292 were collected for 3 years, and comparisons were made between the first quarter of FYs 2008, 2009, and 2010 to assess the impact of the education, documentation, and billing (EDB) process. These periods represent, respectively, the evaluation period before, during, and after implementation of the EDB process.

During the evaluation period, 2 template notes for documentation in the ICU were introduced. The first note represented the daily progress note completed after performance of a 12-hour shift (eFigure 1). This note incorporated systems reviews, system-based plans of care, and documentation of aggregate time devoted to patient care. The second note, the critical care event note (eFigure 2), was used to capture acute events that required time-based critical care intervention not reflected by the daily progress note. The charges were entered into an electronic billing system (PatientKeeper, Inc, Newton, Massachusetts) by the provider or an administrative assistant in the Department of Surgery.

Net revenue, number of surgical ICU patient-days, length of stay, and number of surgical ICU beds were collected for the first quarter of the evaluation period. Fiscal year totals for net revenue received as a result of charges submitted by the GSICU, CTICU, and NICU and the percentage of the AP salary offset were also collected. Data are expressed as mean (SEM) and were analyzed with a paired, 2-tailed t test where appropriate. P < .05 was considered significant.

During the first quarter of FYs 2008, 2009, and 2010, 33 APs provided care for 2004 critical care admissions to the GSICU, NICU, and CTICU. The mean overall length of stay was 5.3 days. The number of beds increased only for the CTICU between FY 2009 (12 beds) and FY 2010 (15 beds), representing a 25% increase in capacity during the study period (Table).

Figure 1 details the charge capture for the first quarter of the 3 periods: FY 2008 represents the period before the intervention; FY 2009, the period during the intervention; and FY 2010, the period after the intervention. During implementation, all units reported reduced submitted charges; however, after implementation of the standardized process, combined charges for CPT codes 99291 and 99292 for all 3 units increased 48% from FY 2008. Independently, each unit demonstrated an increase in charge capture after process implementation: 70% in the CTICU, 39% in the NICU, and 25% in the GSICU.

After implementation, the overall net revenue collected at the end of FY 2010 for all units showed a 40% increase from before implementation of the EDB process (Figure 2). To account for the changes in the number of total beds (because of the 3-bed increase in the CTICU), we analyzed the net revenue per bed for each unit (Figure 3). After implementation of the EDB process, all units showed an increase in the percentage of net revenue per bed. This increase indicates that the improved revenue generation was a result of process improvement and not simply of increased capacity. The GSICU demonstrated the greatest increase in percentage of net revenue per bed (54%) among all 3 units. The AP salary offset (without fringe benefits) increased from 62% to 80% (data not shown).

The results from this study demonstrate a significant improvement in critical care charges submitted and net revenue collected with E&M education and implementation of a standardized critical care documentation practice. This practice resulted in 3 important benefits: a 40% increase in net revenue at the close of the FY following implementation, an 18% increase in ICU AP salary offset, and a 54% increase in the GSICU net revenue despite a mixed staffing model of postgraduate physicians and APs.

Our institution has previously shown that AP staffing in the ICU is an important resource for providing direct and indirect patient care activities, particularly in this era of work-hour restrictions imposed by the Accreditation Council for Graduate Medical Education.⁵ Unlike the postgraduate physician workforce, APs represent a stable cadre of providers in the ICU and are therefore more amenable to maintaining consistency of documentation following educational intervention. Sprtel and Zlabek⁶ reported an approximately 15% increase in billable income when internal medicine residents were educated on medical documentation and when standardized history and physical examination forms were used for hospital admissions during a 6-month period. However, their study did not include critical care codes and examined only the billing codes generated from history and physical examination documentation (CPT codes 99221, 99222, and 99223). Nevertheless, their results underscore the importance of education and repeated use, a paradigm easily incorporated in the surgical ICU when APs replace residents as the primary workforce. In the ICU setting, the use of nonresident providers results in more consistent documentation practices because the APs do not rotate monthly and therefore do not require repeated instruction on basic concepts of E&M documentation. This staffing model not only eliminates the need for monthly educational sessions but also may minimize the negative financial variance that we observed during the implementation phase. Once the process was fully implemented, we further optimized charge capture and prevented overbilling by providing immediate feedback on documentation practices. This feedback strengthened the APs' existing knowledge base of E&M guidelines. More important, these outcomes also occurred in the GSICU where, despite the mixed staffing model, net revenue increased to 54% after implementation.

Marill et al⁷ reported similar benefits of standardized documentation. Marill and colleagues prospectively evaluated the impact of a documentation template used in the emergency department. Outcome measures of physician evaluation time, change in gross billing, and provider satisfaction were evaluated. Overall, they found that the use of a template for documentation in the emergency department was associated with higher gross billing and improved provider satisfaction and had no effect on total physician evaluation time. Our study similarly highlighted the importance of educational programs to increase compliance and improve documentation. Our study did not examine provider satisfaction with the process; however, compliance with submission of documentation was monitored daily, and feedback was given when deficiencies were identified.

Kuo et al⁸ reported their experience on benchmarking E&M coding in an academic division of surgery to increase their revenue stream. Using an internal standard (their transplant service) as a comparison, they were able to project an annual gain of $400 000 to $600 000. Of note, their study did not include critical care or emergency department services. Hendershot et al⁹ reported that missed surgical ICU billing could be identified with an electronic documentation and billing process. Although their study hypothesized that missed night and weekend billings might justify everyday, 24-hour in-hospital attending physician coverage of the ICU, their financial analysis demonstrated that capture of these charges would be insufficient to cover the cost of adding in-house intensivist coverage. The most important difference from the present study is the staffing model in the ICU. In the study by Hendershot et al, the surgical ICU was staffed with residents and supervised by critical care fellows, with oversight by the intensivist. The significance of the present study is the employment of APs in all our ICUs. In fact, even in the GSICU, which does not have everyday, 24-hour AP coverage, we were able to demonstrate a significant improvement in net revenue return. This further underscores the importance of APs, particularly in teaching hospitals, where postgraduate physicians provide most patient care. Advanced practitioners are able to submit E&M charges for aggregate time dedicated to the care of the critically ill patient; this is time that cannot be captured economically by postgraduate physicians.

In conclusion, our results highlight the importance of education and standardization of documentation tools in critical care and the significant role of APs as direct bedside providers in the ICU. Their independence provides an important opportunity to enhance revenue streams that may be missed with a traditional staffing model of postgraduate physicians. In this era of mandated duty-hour restrictions for postgraduate physicians, teaching hospitals must meet the challenge of decreasing availability of residents by providing alternate resources to maintain workflow and ensure the safety and quality of patient care.

Correspondence: Karyn L. Butler, MD, Department of Surgery, Hartford Hospital, 80 Seymour St, Hartford, CT 06102 (kbutler@harthosp.org).

Accepted for Publication: December 20, 2010.

Author Contributions:Study concept and design: Butler. Acquisition of data: Butler and Calabrese. Analysis and interpretation of data: Butler, Tandon, and Kirton. Drafting of the manuscript: Butler and Kirton. Critical revision of the manuscript for important intellectual content: Butler, Calabrese, Tandon, and Kirton. Statistical analysis: Butler. Administrative, technical, and material support: Butler, Calabrese, and Tandon. Study supervision: Butler and Kirton.

Financial Disclosure: None reported.

Previous Presentation: This paper was presented at the 91st Meeting of the New England Surgical Society; October 31, 2010; Saratoga Springs New York; and is published after peer review and revision.