A fiscally sound, evidenced-based solution to conquering the complexity of physician billing guidelines: A physician-centric note template

Abstract

Background: Effective documentation and coding in health care are crucial for patient care, safety, workflow improvement and accurate billing. Objectives: This quality improvement study aimed to enhance History and Physical (H&P) note documentation and charge capture processes to integrate coding and billing aspects, capture authentic work, preserve the H&P’s integrity and align H&P-related revenue with actual performance. Method: A multidisciplinary team, including divisional leadership and specialists in documentation improvement, electronic health records, lean/six sigma methodology, a nocturnist and a senior-level physician coding auditor, initiated a quality improvement project. Educational efforts targeted approximately 50 hospitalists at a Departmental meeting in January 2023 (Department of Medicine, University of North Carolina School of Medicine), followed by the development and iterative testing of a standardised H&P note template in March 2023, officially disseminated to the entire Department in June 2023. Results: Despite limited impact from education alone, the implementation of an updated H&P template in May 2023 and department-wide distribution in June led to an immediate increase in average work relative value units (wRVU) per encounter, driven by enhanced capture of prolonged time codes and key medical decision-making phrases. The sustained correlation between template usage and increased wRVUs demonstrated a consistent, elevated plateau compared to the education phase. Conclusion: Collaboratively designed and user-informed note templates, balancing usability, efficiency and revenue-generating elements, proved more effective than education alone in integrating complex changes into clinical practice and enhancing coding and billing accuracy. Implications: Results of this study underscore the benefits of standardised documentation tools in enhancing both clinical and financial outcomes, suggesting that healthcare institutions could improve revenue capture, and documentation accuracy by adopting similar approaches.

Introduction

Effective provider documentation is critical in ensuring quality patient care, enhancing patient safety and accurately reflecting provider activity translated into appropriate code capture and medical billing. In medical billing and coding, particularly in the United States, the precision and accuracy of documentation in patient care are paramount. It is imperative for institutions and medical practices to adeptly capture patient diagnoses, procedures and the nuanced services provided by healthcare practitioners to both accurately record the care provided and for strategic health system planning.(So et al., 2010) However, achieving this level of precision can be challenging, with certain areas prone to inadequacies and inputting errors.(Childers and Maggard-Gibbons, 2022)

Due to the complexity and individuality of physician and clinic or hospital factors, there is a wide variation in documentation quality. Studies have acknowledged that institutions with poor documentation practices can have poor translation of clinical data into administrative data resulting in far-reaching adverse effects, including missed billing and clinical coding opportunities and of more significant concern, possibly suboptimal quality of care (So et al., 2010) In the United States, reimbursement for services as well as institutional metrics are largely regulated by Centres for Medicare and Medicaid Services (CMS) specifications. Documentation specialists extract information from provider notes, and this information is reconstructed into a clinical coding system used for billing purposes as well as other important medical centre indices including reimbursement, length of stay, mortality indices and others. Hospitalists, particularly, have voiced frustration over the absence of specific clinical coding information in Current Procedural Terminology (CPT) and Evaluation and Management (E/M) clinical codes tailored to the nuances of Hospital Medicine (HM). A significant shift occurred on 1 January 2023, with the American Medical Association (AMA) introducing updated E/M clinical codes and guidelines.

The 2023 E/M billing procedures underwent a transformative change, emphasising complexity, medical decision-making, and time, while history and physical (H&P) exams were phased out as elements in determining code selection. These changes also included eliminating the added complexity of requiring separation between inpatient and outpatient codes that was established in 2021. Despite many positive aspects, such as eliminating the need for an extensive physical exam and improving the capture of prolonged service time, healthcare systems faced the challenge of swiftly adapting to the remodelled coding system (Richard, 2022). It was evident that the E/M changes would significantly directly impact billing, clinical coding and reimbursement. Thus, immediate efforts were made to adapt quickly and precisely to maintain financial stability and ensure sustainability.

The 2023 modifications to the E/M framework served as the catalyst for our hospital medicine division to embark on a quality improvement initiative aimed at re-evaluating our existing provider H&P note documentation and charge capture processes. In light of the E/M system overhaul, we applied the principles of the “hierarchy of effectiveness,” emphasising system-focused strategies such as forcing functions and automation over traditional educational interventions (Soong and Shojania, 2020) to guide our approach. Previous studies have shown that structured, standardised documentation resulted in improved note quality and improved communication among healthcare providers (Ebbers et al., 2022). Additionally, adequately formulated and optimised templated notes can reduce documentation burden on providers, and optimising physician notes can save time for patient care, and improve physician satisfaction (Alissa et al., 2021). Other studies have reported templated notes maintain the benefits of personalisation while leveraging standardisation to reduce documentation burden (Rosenbloom et al., 2011; Rule and Hribar, 2021).

The overarching goal of this initiative was to establish synergy between provider documentation and billing practices through creation of a H&P template which seamlessly incorporated accepted language aligned with the updated guidelines, facilitating the creation of comprehensive notes that incorporated essential coding and billing elements. To further reduce provider cognitive load, optimise coding capture and to promote real-time review of key patient data, the template should include supporting phrasing for the provider’s work in reviewed and analysed data, articulating the provider’s perspective on patient-specific risks of management and accommodating prolonged care time options. As a core tenant of the H&P template quality improvement project was to balance the desire to achieve improved documentation practices and billing capture in response to the updated 2023 E/M guidelines with the core value of maintaining the integrity and quality of patient care by producing accurate and transparent documentation, our project sought to achieve four primary objectives:

1. Integrate critical aspects of coding and billing guidelines seamlessly, eliminating the need for users to refer to external materials.

2. Accurately capture performed work in a manner that resonates authentically with end-users.

3. Preserve the integrity of the H&P as the primary communication tool by minimising non-value-added verbiage and unnecessary interactions.

4. Enhance our group’s H&P-related revenue (relative value units or RVUs) to align with actual performance.

Method

The population for the H&P template initiative was the University of North Carolina (UNC) Medical Center Hospital Medicine Division, which is comprised of approximately 50 practising hospitalists. These providers practised across two hospital campuses: a 923-bed, non-profit, public, research and academic medical centre located in Chapel Hill, North Carolina, providing tertiary care for the Research Triangle, surrounding areas of North Carolina; and a 68-bed community-based hospital in Hillsborough, North Carolina.

The H&P was selected as the note type for this intervention as this diverse and highly clinically active group performs thousands of unique H&P encounters each year, and there is substantial volume and revenue associated with this encounter type. Data extracted by pulling encounters with a service date between 1 January 2022 and 31 December 2022 and current procedural codes (CPT codes) 99218–99220 and 99221–99223, with data filtered to isolate H&Ps completed by direct attending care and excluded teaching services involving residents, showed that the target population for the intervention performed 3906 unique H&P encounters in 2022, accounting for 13,614 work RVU (wRVU) and resulting in over $690,000 in net revenue (Figure 1).

Figure 1.

H&P encounters for 2022.

H&P: history and physical.

A strategic team comprised of divisional leadership, a physician documentation improvement specialist, a physician clinical informatics specialist, a physician lean/six sigma methodology specialist, a nocturnist who performs mainly admissions and a senior-level physician coding auditor with business-related data analysis skill sets revenue cycle specialist and physician coding auditor spearheaded the quality improvement project to ensure providers could readily capture hospitalists’ clinical work in accordance with the new guidelines while not overburdening them with increased tasks and extensive education.

Efforts undertaken to improve provider documentation prior to our intervention focused solely on education of providers and did not result in an observable change in provider practice. These efforts included intermittently scheduled educational sessions to update providers on the new billing and coding guidelines as well as a targeted review of capture opportunities coupled with encouraging changes in documentation practices and placement of documentation improvement reference cards near hospitalist computer workspaces. Additionally, there was a structured educational session to delineate the new guidelines and prolonged billing codes with coding and billing specialists provided to the hospitalist group at the end of January 2023.

Based on currently available evidence in quality improvement and strategies for facilitating changes in provider practices (Soong and Shojania, 2020; Vogus and Hilligoss, 2016), our team recognised that education alone would likely be insufficient for busy practicing hospitalists to remember the multitude of prior and current documentation needs in a manner that allowed integration of the necessary documentation practice changes into their day-to-day workflows. A standardised H&P note template, combined with education on its proper use, was deemed more efficacious to communicate and implement both new and long-standing capture opportunities (Nguyen et al., 2017; Woods et al., 2008) into provider practice. The objective was to not only cultivate provider awareness but also to automate advantageous optional documentation practices in a manner that did not require physicians in our group to achieve mastery of existing and new AMA E/M guidelines and memory recall.

Our Department, since inception, had been using a standardised templated note to document and H&P’s through SmartPhrases. SmartPhrase templates insert the template’s contents at any specified location and can be the foundation of an entire document. “These templates can contain static text, lists of text alternatives to be selected from a dropdown menu (e.g. the patient was {agitated, calm}), links that import data (e.g. @AGE@) and placeholders for manually typed text (i.e. ***)” (Rule and Hribar, 2021)

Based on our existing templated note, development of an updated comprehensive H&P template began in March 2023. This template introduced “forcing functions” as embedded accessible additional optional drop-down menus, strategically incorporating appropriate and accepted verbiage required for capture. The new H&P note featured four embedded optional dropdowns covering: Severity of illness, complexity of management tailored to common scenarios for our team’s patient population, data review documentation and time-based billing modifiers with the inclusion prolonged service time (Figures 2 and 3).

Figure 2.

Example of partial dropdown list to support medical complexity.

Figure 3.

Example of partial dropdown list to support medical decision-making.

In May 2023, to facilitate incremental, successive (Plan-Do-Study-Act) PDSA cycles within small batches, the H&P note template underwent initial usability testing trials by the project members during admitting shifts to gather data to optimise the template. This limited trial period allowed for hands-on experience to discern the template’s limitations and areas of weakness more effectively. In the succeeding phase, key change agents from the Division of Hospital Medicine were enlisted as additional beta testers for the template. (We defined “key change agents” as those individuals who could not only improve the template design given their wisdom and experience but whose buy-in was felt essential to positively influence the practices of our group by reducing resistance to integration.) This introduction was coupled with in-person “just-in-time” education sessions. After testing, input and feedback were actively sought and feedback obtained post-use was meticulously assessed to drive further refinements to the template prior to departmental dissemination. Throughout this trial period, our coding auditor specialist meticulously scrutinised submitted H&Ps to identify potential weaknesses in template verbiage. The template was then iteratively revised based on feedback. The final version, refined through this comprehensive iterative process, was officially released to the entire department in June 2023.

RVU data were collected via a documentation specialist. Professional billing data for CPT codes 99221, 99222, 99223, 99418 and G0316 (Appendix Table 1) reflecting initial hospital care (H&Ps) and prolonged care for dates of service 1 January 2023 through 31 October 2023 for hospitalists bill area were pulled. Data were filtered to isolate H&Ps completed by the affected service lines only, excluding other service encounters. Physician schedules were cross-referenced to validate service line and provider accuracy. Prolonged care codes were matched to the isolated admissions. Non-matched prolonged care encounters were removed from the data set. H&P finalised raw data inclusions were pivoted by month with encounter counts, and the sum of wRVU. H&P note usage was pulled for only our hospitalist group. Exclusions included groups that were not actively using or providing education on the use of the new template, namely: residents, APPs, medical or APP students, Pre-OP H&Ps, subspecialty consults documented under H&P note classification, and advanced care at home inclusions.

Prolonged care finalised raw data inclusions were pivoted by month with encounter counts, procedure quantity counts (units) and sum of wRVU. Prolonged care code variations 99418 (AMA) and G0316 (Medicare) were rolled into a prolonged care category for encounter counts and procedure quantity counts (units). Prolonged care sum of wRVUs maintained appropriately associated wRVU for CPT origins (99418 = wRVU 0.81 /G0316 = wRVU 0.61). E/M distributions by month were calculated by encounter counts per level of service. Average wRVU per encounter was calculated by month – the sum of wRVU (including prolonged care w/ payor variability in associated wRVU by CPT (99418/ G0316) maintained and including all units)/ total encounters (excludes prolonged care encounters as add-on to base code and not additional encounter). A control chart was created in Excel with 3 σ control limits. Mean and standard deviation were based on the control period of January 2023 and April 2023. Results were cross-tabulated with the new provider template utilisation rate data to see the correlation of template usage with change in wRVUs including prolonged care codes.

Results

The data obtained revealed that educational sessions alone did not bring about substantial changes in provider practices nor wRVUs. However, upon the initiation of the new H&P template usage, initially through small-scale testing with specific admitting providers in May 2023, followed by broader departmental distribution in June, an immediate surge in average wRVU per encounter was evident. This increase was similarly noted in the enhanced capture of prolonged time codes (99223 with Prolonged), and there was also a clear shift towards an increase in 99223 (level 3/ High medical decision-making (MDM)) with a corollary decrease in 99222 (level 2/Moderate MDM) billing (Figure 2). The distinction between 99223 and 99223+ prolonged lies mainly in that 99223 can be based on MDM or time, while 99223 + prolonged is 100% time-based (Figures 4–6).

Figure 4.

wRVU per encounter over time and intervention initiation indicators.

wRVU: work relative value unit.

Figure 5.

Hospitalist billing capture of prolonged care code over time.

wRVU: work relative value unit.

Figure 6.

Average wRVU per encounter with template utilisation.

wRVU: work relative value unit.

Examining the H&P template usage graphs alongside the average wRVU per encounter, including Prolonged Billing time, indicated a clear correlation between the new template usage and average wRVU (Figure 3). Prolonged time capture proved an unanticipated and impactful driver in increasing wRVUs. The rate of increase in wRVUs is notably sustainable over time and demonstrated a constant, significantly increased plateau from the education phase.

Discussion

For decades, achieving concordance of provider documentation with established billing and coding guidelines has been a persistent challenge. The recent changes in billing and coding regulations in 2023 underscored an imperative need for a recalibration of our existing provider documentation processes. Integrating these modifications into providers’ notes and workflows has helped capture performed services in a format recognised within the billing domain. This adjustment has also reduced the cognitive burden on providers, allowing them to concentrate more on essential patient care needs and less on remembering the documentation required for coding.

The project team realised at the onset of the project that hospitalist providers at our institution were already routinely doing the necessary work that could result in higher billing under the previous and new guidelines but that work wasn’t being effectively captured because individual providers either didn’t know how to document it correctly or had other precluding factors preventing them from incorporating the necessary verbiage consistently into documentation.

Our study demonstrated templated notes with built-in options for capturing appropriate E/M terminology improved charge capture more effectively than our passive education efforts alone. Providing handouts and discussing documentation changes was insufficient in enabling our providers to effectually adjust their documentation to meet the new 2023 E/M coding guidelines. The templated notes, tailored to our hospitalist group, streamlined the documentation process, reducing the cognitive load on providers. The significant increase in wRVUs after implementing the template underscores its effectiveness. Providers were better equipped to document the complexity of their work using the correct language. Previous studies have shown statistically significant improvements in quality measures after instituting templated notes while simultaneously reporting deceased provider burden (Cao et al., 2017).

Our data analyses revealed that the impact of the MDM phrasing was a key factor in wRVU increases. The efforts related to MDM are also now easily captured by coders by providing a regular location in documentation to find the necessary content and consistent use of the appropriate necessary language.

While also very impactful for wRVU increases, the effect of prolonged time was more of an unanticipated bonus than the catalyst for the project. Despite the long-standing knowledge of prolonged care codes, our study highlighted that making the new, simplified requirements for this code accessible to providers led to a tangible improvement in capturing services, even without additional education. Thus demonstrating when both a reminder-trigger for inserting the necessary information and appropriate options to choose from that align with work performed were incorporated, this hurdle and burden diminished. “Change is hard because people wear themselves out. . . What looks like laziness is often exhaustion” (Heath, 2010). Vogus and Hilligoss (2016) noted that high reliability has remained elusive in health care because organisations have failed to recognise the central role of habit. These tenants have been a cornerstone of the template design, as was the goal to better capture that work that was already being done rather than asking the group to “do more.”

Our findings regarding poor performance post passive educational interventions alone align with other studies. The medical literature suggests that passive education, such as lectures or distributing information, is generally ineffective in changing workflows or habits. While education plays a role in helping providers comprehend the necessity of an intervention, it alone can fall short of fostering meaningful change. Strategies that make the necessary “thing to do” easier for providers to accomplish are markedly more successful (Ebbers et al., 2022; Education is “predictably disappointing” and should never be relied upon alone to improve safety | Institute For Safe Medication Practices, n.d.; Medication Error Prevention “Toolbox” | Institute For Safe Medication Practices, n.d.; Epstein et al., 2021; Grogan et al., 2004; Haynes et al., 2009; Heath, 2010; Lorenzetti et al., 2018; Rose et al., 2001; Santoro et al., 2021; Schaeffer et al., 2021; Seligson et al., 2021; Soong and Shojania, 2020; Starmer et al., 2014).

As outlined in the Institute for Safe Medication Practices (Medication Error Prevention “Toolbox” | Institute For Safe Medication Practices, n.d.) and described by Soong and Shojania (2020), the classic ‘hierarchy of effectiveness’ education ranks as the least effective intervention, directly under new rules and policies and well below more system-focused categories such as forcing functions or automation. Passive educational activities yield particularly low impact. Active educational strategies can achieve better outcomes similar to those of audit and feedback and computerised decision support. While active educational interventions tend to produce greater improvements than passive ones, they also require greater investments of personnel time; hence, their lower uptake as improvement strategies.(Soong and Shojania, 2020)

Limitations

Our study has limitations, primarily, its focus on comparing the impact of education and awareness initiatives with the new template without delineating the relative contribution of each factor to the observed outcomes. Additionally, there was no long-term direct comparison of the two independent groups, introducing a potential limitation in the study design. Due to the large overhaul of the clinical coding system, we were not able to strictly compare wRVUs directly to the prior year. Another concern arises from the varying application or adherence to the intended workflow of the template among different end-users, which may introduce variability in the results. Lastly, the process of template creation and implementation relied on feedback solicited from various participants, potentially representing a subset of users and not capturing the perspectives of the entire user base.

Future projects could focus on ongoing template education to ensure sustained physician buy-in and optimal utilisation of templated sections and addressing potential challenges and barriers. Exploring the extension of the template approach to consultation and progress notes could be valuable, given the financial impact of subsequent care note encounters. For these efforts, consideration should be given to the challenges of copying and pasting in the current charting climate. Additionally, future studies may seek more specific and comprehensive provider feedback, both qualitatively and quantitatively, to gain insights into the nuances of template use and its impact on documentation practices. The generalisability of the study could be further delineated by disseminating the addition of effective parts of the current template to other services in the hospital. This way we could assess its applicability and effectiveness across our diverse healthcare settings. Finally, a more in-depth exploration of the financial impact, including cost-effectiveness and revenue outcomes, could provide a comprehensive understanding of the template’s implications beyond the immediate increase in average wRVU per encounter.

Conclusion

Relying solely on passive education was inadequate in our institution to effectively integrate complex changes into clinical practice. Instead, a well-crafted note template for providers proved to be a powerful tool, enhancing the capture of provider work, improving coding and billing accuracy and also providing active education to physicians on optimal revenue-generating documentation practices. The ideal design of such a template is achieved through collaborative efforts within an institution. Striking a balance between usability, efficiency and including revenue-generating elements becomes crucial for ensuring sustainable effectiveness in clinical practice.

Appendix

Table A1.

Reference for time-based billing codes.

Encounter Type	CPT	Total face-to-face and non-face-to-face time thresholds (minutes)
Initial	99221	40
	99222	55
	99223	75
Subseq	99231	25
	99232	35
	99233	50
Consultation	99252	35
	99253	45
	99254	60
	99255	80

CPT: current procedural terminology.