Billing and Coding Rounds: Turning Daily Encounters Into Dollars and Sense

Abstract

Introduction

While hospitalists dedicate substantial time to documentation, incomplete or inaccurate coding causes large, preventable revenue losses. Recent updates to evaluation and management guidelines allow visit level to be determined by either the complexity of medical decision-making or total clinician time, including documentation. However, limited training means physicians may underutilize these updates, contributing to financial shortfalls.

Methods

A 5-part curriculum delivered in 15-minute virtual sessions over 6 months was designed to improve documentation, billing accuracy, and reimbursement without adding work for faculty. It combined brief didactics with interactive cases or “billing rounds,” an electronic health record smart phrase, a concise reference “cheat sheet,” and targeted feedback to the lowest performers. Pre- and postcurriculum surveys and billing data analysis measured changes in confidence and objective performance.

Results

Fifty-six hospitalists participated (42.9% completed presurvey and 37.5% postsurvey). Respondents reported increased confidence in billing from pre- to postcurriculum. The proportion reporting very or completely confident increased: overall billing (25% to 57%), admission notes (38% to 81%), progress notes (33% to 76%), discharge summaries (46% to 95%), and billing critical care (29% to 52%). Objective documentation and coding improved substantially over 6 months: more discharge summaries included time statements, critical care encounters were billed more often, and higher-level evaluation and management codes were used more frequently, generating over ∃150,000 in additional revenue. Overall, work relative value units increased 77%.

Discussion

This curriculum led to gains in documentation quality and reimbursement, demonstrating that tightly targeted, workflow-embedded billing education can close key revenue-integrity gaps.

Educational Objectives

By the end of this activity, learners will be able to:

• 1.Determine billing levels for admission and progress notes using medical decision-making criteria and total time.
• 2.Apply critical care service codes when clinically applicable.
• 3.Document discharge summary and prolonged service time statements that meet coding requirements.
• 4.Distinguish between professional and hospital-based billing models and hospitalist documentation practices that contribute to each.
• 5.Define work relative value units and their relationship to Current Procedural Terminology codes.
• 6.Use precise diagnostic terminology in documentation to capture patient severity and complexity within diagnosis-related groups.

Introduction

Hospitalists devote a substantial portion of the workday to documentation, with observational studies showing that clinicians spend roughly 40% of their time on documentation-related tasks, often exceeding the time spent in direct patient care.^1,2 Despite this investment, incomplete or inaccurate capture of services in billing and coding leads to sizable lost revenue at both the hospital and national levels. Simultaneously, many hospitals in the United States are operating under sustained financial pressure, with margins still below prepandemic levels and at risk of further erosion from rising uncompensated care and persistent cost growth, especially for general acute hospitals.³

Revisions to evaluation and management (E/M) billing guidelines beginning in 2021 and expanded in 2023 shifted code selection away from detailed history and examination bullet points toward 2 main pathways: complexity of medical decision-making or total time spent on the date of the encounter. Under these updates, “total time” explicitly includes both face-to-face and non–face-to-face work personally performed by the billing clinician on that date, such as reviewing records, documenting, and communicating results, thereby allowing more of the documentation burden to be reflected in billable time-based codes.⁴ For hospital and observation services, the 2023 changes aligned inpatient codes with the 2021 office visit framework, defining time thresholds for each code (eg, specifying total minutes required for initial and subsequent inpatient visits) and introducing prolonged service add-on codes when clinician time exceeds those thresholds.

Despite the potential revenue and compliance benefits of these guideline changes, many frontline clinicians, including hospitalists, remain only partially aware of the specifics of the 2021 and 2023 E/M revisions or are unsure how to apply them in daily practice. This knowledge gap reflects a broader trend in medical education, where formal training in documentation for billing, coding, and revenue cycle optimization is limited compared with training in clinical diagnosis and treatment, leaving many physicians reliant on informal learning or coders to interpret complex rules.^5–7 A local needs assessment survey found that hospitalist faculty at our facility perceived substantial gaps in billing training during residency and new hospitalist onboarding, along with inadequate feedback from the billing and coding team (Table 1). Professional societies and specialty groups have begun offering guides, workshops, and online learning to close this gap, but participation is variable, costs to learners can be substantial, and competing clinical demands often limit the time clinicians can devote to mastering evolving coding requirements.^8,9

Table 1. Participant Responses to Local Needs Assessment Survey (N = 24).

On a national scale, poor billing and coding practices—often rooted in documentation deficiencies or misunderstandings of coding rules—are estimated to cost US physicians and health care organizations approximately $125 billion per year in lost revenue. Analyses suggest that a significant fraction of this loss stems from preventable issues such as undercoding, missing charges, and documentation that does not fully support the complexity of care provided, rather than from outright claim denials alone. Industry reports further indicate that hospitals may lose 3%–5% of their revenue annually due in part to insufficient clinical documentation and inaccurate coding, underscoring how the mismatch between documentation workload and effective billing translation has major implications for institutional financial health and sustainability.¹⁰

While Lynch and Oller¹¹ described a curriculum in 2023 to enhance internal medicine residents’ proficiency with 2021 outpatient E/M billing guidelines, MedEdPORTAL lacks comparable resources addressing the 2023 inpatient and observation E/M revisions or tailored for faculty hospitalists—who bill daily and require fluency in these updated standards to optimize revenue cycle performance. This gap is notable because educational interventions have been demonstrated to improve billing compliance in other learner groups, including residents and medical students, suggesting that structured instruction can improve understanding and application of coding principles. Training in this area has relied heavily on lecture-based instruction and on limited evaluation methods, most often knowledge-based testing or billing outcomes alone.^12,13 A 2022 review of outpatient billing practices noted that effective interventions in the literature included didactic sessions, pre/post testing, formal feedback and correction, and medical record documentation tools.¹⁴ Accordingly, this curriculum was developed to provide hospitalists with practical training on the most recent inpatient E/M changes. We aimed to develop targeted education with “billing rounds” exercises to consolidate knowledge gained in the didactic portion and promote application of coding principles in authentic case-based scenarios. Case-based learning is well suited to this topic because it mirrors real clinical workflows and encourages learners to apply coding knowledge to realistic inpatient scenarios. This active approach boosts critical thinking, problem solving, and retention over passive lectures, as learners justify coding levels, time, and modifiers—a practice directly transferable to daily documentation.¹⁵ We also sought to incorporate multiple evaluative strategies to track learner progress and reinforce instruction through lectures with feedback, a concise reference handout or “cheat sheet,” and point-of-care tools.

Methods

Our team developed this curriculum for practicing attending hospitalists in the Division of Hospital Medicine at Oregon Health and Science University (OHSU), all credentialed in inpatient medicine and routinely using Epic for admissions, progress notes, and discharges. Learners were expected to have baseline competency in inpatient documentation and general familiarity with core E/M concepts, but no prior formal training in billing, revenue cycle management, or diagnosis-related group (DRG) optimization was required. Facilitators were hospital medicine faculty with support from billing specialists at our institution, who are experienced in professional and facility billing workflows, institutional billing rules, Epic configuration, and current E/M guidelines.

We created this activity to streamline documentation, reduce variability, improve billing accuracy, and optimize reimbursement without increasing net documentation time for hospitalists. The intervention consisted of a 5-part billing and coding curriculum delivered in 15-minute segments over a 6-month period to all hospitalists in the division. Sessions were scheduled during existing monthly division meetings, ensuring broad attendance without requiring additional protected time. Hospitalists participated as learners while 1 or more hospitalist educators led sessions. Billing and coding specialists validated content and practical examples—and provided aggregate feedback about actual billing practice for individuals. Hospitalist educator faculty shared individualized and aggregate feedback to support application in daily practice.

Each of the 5 sessions focused on a distinct portion of the billing spectrum for hospitalists. The first session (Appendix A) emphasized accurate selection of admission and subsequent visit codes using medical decision-making and total time spent, highlighting how to fully capture non–face-to-face work such as record review and documentation. The second session (Appendix B) addressed correct application of critical care billing, including documentation requirements to support time thresholds and complexity. The third session (Appendix C) focused on discharge documentation requirements and prolonged service codes, highlighting the importance of time statements to support either. The fourth session (Appendix D) focused on work relative value units (wRVUs) and demonstrated their relationship to time, technical skill, mental effort, judgment, and stress/risk involved in caring for a patient for a given Current Procedural Terminology (CPT) code. Finally, the fifth session (Appendix E) centered on the distinction between professional billing and hospital-based billing, stressing how the appropriate use of precise diagnostic language to reflect patient severity and complexity affects DRGs through capturing key comorbid conditions and complications. Sessions included interactive “billing rounds”—case-based examples where facilitators modeled coding decisions and learners applied new concepts in real time. The curriculum was delivered virtually in five 15-minute video meetings. All questions for case-based learning are compatible with audience response systems such as Slido or Poll Everywhere.

Several resource components were also integrated in a defined sequence across the 6-month implementation.

At the outset of the first session, we created and shared a new Epic dot phrase (aka, electronic health record [EHR] smart phrase; Appendix F)—configured to appear at the bottom of inpatient notes. This was launched and demonstrated with screenshots of live use. Hospitalists were shown how to insert the dot phrase and use the pull‑down menu to select key billing elements, including problem, data, and risk complexity at the point of care. In subsequent sessions on critical care, prolonged services, and discharge coding, the same dot phrase was revisited to show how to incorporate time documentation and specific critical care elements. Facilitators walked through example scenarios, emphasizing how use of the dot phrase could standardize capture of required elements across providers.

We also created a 3-page reference handout or “cheat sheet” (Appendix G) of high-yield billing and coding points that was introduced, printed, and distributed to all workstations in the team room so that hospitalists could reference it while writing and billing admission, progress, and discharge notes on a day-to-day basis.

Throughout the 6-month period, we periodically shared individualized feedback reports—prepared using actual billing performance metrics—with providers in the lowest quartile for each topic area (eg, underuse of higher-level admission codes despite appropriate complexity, low critical care billing rates, or lack of discharge time statement). These feedback interactions occurred outside the brief didactic sessions, via email follow-up, allowing targeted coaching. Physician curriculum designers provided this coaching based on individual-level data from the institutional billing and coding team.

A preeducation survey (Appendix H) was administered before the first session to all participating hospitalists to assess baseline confidence and self-reported billing and coding practices. Likert-scale survey items were developed by the curriculum team in collaboration with billing specialists to align with curriculum learning objectives and were piloted in a small group of hospitalists to ensure clarity and face validity. A matching posteducation survey (Appendix I) was administered after completion of the 5-part curriculum, near the end of the 6-month period, to evaluate changes in confidence in billing progress notes, admission notes, discharge summaries, and critical care; self-reported behaviors including frequency of billing critical care, prolonged service, and less than 30-minute discharge summaries; and perceptions of the curriculum content. Pre- and postintervention Likert-scale survey responses were compared as independent aggregates using chi-square tests of independence for categorical outcomes. Short open-ended survey responses were analyzed using a thematic content analysis approach, in which 2 investigators independently reviewed and coded comments, met to reconcile codes, and identified recurring themes.

Our evaluation strategy integrated survey-based measures of educational impact (confidence and self-reported behavior) with objective billing performance before and after curriculum implementation. Billing specialists used existing billing data to examine shifts in the distribution of E/M levels for admission and progress notes; the frequency and appropriateness of critical care and prolonged service billing; discharge code/discharge time statement usage; aggregate wRVUs; and indicators of improved capture of patient severity and complexity, including the institutional case mix index (CMI). This framework therefore linked self-reported learning outcomes from surveys with quantitative billing data, enabling alignment of observed documentation and billing changes with the pre- and postintervention periods.

Additional materials necessary for implementation included access to Epic with the dot phrase live in the production environment, printed copies of the 3-page reference handout or “cheat sheet” summary placed at each workstation, and standard audiovisual equipment used for divisional educational conferences. The project was submitted to the OHSU Institutional Review Board and deemed not human research and thus exempt from further review (STUDY00029714: January 26, 2025).

Results

The curriculum was implemented for all 56 practicing hospitalists in the division of hospital medicine, targeting attending physicians (and advanced practice providers) regularly responsible for inpatient admissions, daily progress notes, critical care documentation, and discharges on hospitalist-only or resident teaching teams. Across the first 6 months of implementation, all hospitalists in the division were exposed to the intervention through the 5-part curriculum, integration of the Epic dot phrase into daily workflow, distribution of the 3-page reference handout or “cheat sheet,” and individualized feedback to lower-performing individuals.

After 6 months of implementation, clinicians demonstrated meaningful improvements in billing performance and coding accuracy. The inclusion of time statements in discharge summaries increased from 60% preintervention to 83% postintervention, supporting more consistent and appropriate use of higher-complexity discharge codes. This change drove an increase in billing of CPT 99239 (ie, hospital discharge day services over 30 minutes) and was projected to yield more than $39,000 in additional revenue over the measurement period. The frequency of critical care billing rose by 130% after the curriculum and dot phrase rollout, suggesting that hospitalists were better able to recognize and document encounters that met critical care criteria, which generated approximately $47,000 in additional revenue. High-complexity (level 3) billing codes (CPT 99223 for admission/initial visit notes and 99233 for subsequent visits) increased by 27%, whereas low-complexity (level 1) billing codes (CPT 99221 for initial and 99231 for subsequent visits) decreased by 5%, consistent with improved alignment of documented medical decision-making and total time with appropriate code selection, and generating roughly $51,000 in additional revenue. The wRVUs increased by 77% following implementation, indicating substantial impact on the level of productivity and financial recognition of the services provided. The institution's CMI increased from 2.58 in fiscal year 2025 (prior to the intervention) to 2.68 in April 2026 (following the intervention).^16,17

A total of 24 of 56 participants (42.9%) completed the presurvey, and 21 of 56 participants (37.5%) completed the postsurvey. These data demonstrated statistically significant improvements in confidence in overall billing and coding knowledge, as well as in selecting the appropriate level of service for progress, admission, and discharge notes and applying critical care modifiers. Respondents reported decreased use of discharge summary billing at the less than 30-minute level and increases in billing for critical care and prolonged services, with these latter practices showing large effect sizes. However, changes in self-reported discharge summary billing and in billing behavior when uncertain (greater likelihood of selecting a higher code when ambivalent) did not reach the threshold for statistical significance (Table 2).

Table 2. Average Pre- (N = 24) and Postsurvey (N = 21) Responses for Billing Confidence and Self-Reported Behaviors.

Participant evaluations of the curriculum were highly favorable. Most respondents strongly agreed that the curriculum was high quality and well structured and effectively covered essential billing and coding concepts. Case-based learning was particularly well received, with most participants strongly agreeing that the examples were effective and realistic. Supplementary materials were also viewed positively: most respondents agreed the reference handout or “cheat sheet” was a valuable tool and clearly explained key rules, whereas the Epic smart phrase was reported to enhance coding efficiency at the point of care (Table 3). Short open-response survey questions indicated that participants viewed the curriculum as highly valuable, practical, and tailored to their hospitalist workflow, with many reporting a clearer understanding, fewer billing errors, and meaningful improvements in billing practices and perceived revenue. Comments emphasized clear objectives, tangible and immediately applicable recommendations, and delivery in relatable language while also calling for ongoing sessions.

Table 3. Participant Responses on Overall Quality and Success of the Workshop (N = 21).

Overall, the impact of the resource was evaluated by examining both participant perceived and objective billing and productivity metrics before and after implementation, aligning with higher levels of Kirkpatrick's model (levels 3 and 4: behavior and impact). Behavior change was reflected in measurable shifts in documentation content and code selection, such as the increased inclusion of time statements in discharge summaries and more frequent and appropriate use of critical care and higher-level E/M codes. These behavioral changes, in turn, produced clear level 4 impact outcomes, including the estimated revenue gain yield of nearly $150,000 across all professional billing types. The substantial 77% increase in overall wRVUs provided further evidence that the curriculum and Epic dot phrase not only improved coding accuracy but also ensured that the complexity and intensity of hospitalist work were more accurately captured.

Discussion

This educational innovation produced measurable improvements in documentation practices and substantial financial gains for the hospitalist group. By integrating a focused curriculum with workflow-embedded tools, the initiative enabled hospitalists to consistently apply current billing reforms in their daily work, enhance documentation quality linked to billing requirements, and optimize reimbursement in the inpatient setting. Follow-up observations suggest continued improvement over time, though a formal longitudinal evaluation is needed to confirm the durability of behavior change. Importantly, this work builds on prior literature demonstrating that structured billing education can improve coding accuracy and compliance while extending it to a previously underrepresented domain—faculty hospitalists navigating the 2023 inpatient and observation E/M revisions.

The development and implementation of this work highlight several key lessons. First, a targeted, hospitalist-specific curriculum that addresses real local financial pressures and observed documentation variability can rapidly affect both behavior and revenue when content is tightly aligned with daily practice. In contrast to prior curricula that have focused largely on trainees or outpatient billing changes, this intervention was designed for practicing hospitalists who require immediate, practice-ready fluency in updated billing standards. Second, embedding education into existing workflows (eg, brief sessions, reference sheets at workstations, and point-of-care tools) lowers barriers to adoption and helps translate abstract billing principles into concrete documentation habits. Where prior studies have relied heavily on lecture-based instruction and knowledge testing alone, our use of case-based “billing rounds” provided an active learning approach that mirrors real clinical workflows and promotes application of coding principles in authentic scenarios. The results indicate that the intervention effectively addressed the initial problem of inconsistent, suboptimal billing and documentation practices, demonstrating that focused education can close critical knowledge and practice gaps in revenue integrity. This aligns with prior literature suggesting that multimodal interventions—combining didactics, feedback, and applied practice—are most effective in improving billing behaviors. Third, active collaboration between hospitalist educators and institutional billing specialists was critical to success. Billing specialists validated content accuracy, provided real-world examples aligned with hospitalist workflows, and generated individualized performance feedback that enabled targeted coaching. For institutions seeking to replicate this work, we recommend early engagement of billing and revenue cycle teams as true curricular partners—not just content validators—ensuring alignment with coding guidelines, access to actionable billing data for feedback, and integration of documentation tools within the EHR.

There are, however, important limitations and considerations for generalizability. The resource was developed within a single academic health system, with a specific EHR configuration, local billing infrastructure, and hospitalist culture; institutions with different EHRs, payer mixes, or staffing models may require adaptation of both content and tools. Several components are highly generalizable across adult hospitalist groups and institutions, including the didactic content on 2023 inpatient and observation E/M guidelines, case-based “billing rounds” exercises, the pre/post assessment strategy, and the overall curricular structure of brief sessions embedded in existing meetings. In contrast, the Epic dot phrase may need to be redesigned for other EHRs (or replaced with alternative documentation templates), and individualized billing feedback depends on local billing system access and collaboration with revenue cycle teams. The core principles and case-based approach could be adapted to other audiences (eg, pediatric hospitalists, outpatient clinicians, or other inpatient specialties) by tailoring scenarios and code sets. Preliminary experience sharing this curriculum with a community adult hospitalist group suggests similar perceived value and applicability, though objective billing outcome data from that setting were not available. Additional limitations include challenges with having all hospitalists attend scheduled meetings for various reasons, including clinical care and time off. To address this, we made both slides and recorded versions of each live session available to our teams after each session for asynchronous review. In settings with less supportive billing departments, collaboration and feedback may be more difficult than in our academic health system. That said, while the summative and individualized billing feedback are valuable, they are not required elements and groups could rely on self-assessment survey data and routinely available billing reports. Finally, the evaluation strategy relied heavily on billing and revenue outcomes, which, while meaningful, may be influenced by operational changes, seasonal case mix variation, and policy shifts, making attribution to the curriculum alone imperfect. In particular, CMI trends may reflect more precise documentation to capture patient acuity and complexity within DRGs but may also relate to an increasingly quaternary care patient population at our institution. Without more granular and longer-term assessment (eg, direct chart audits, multisite replication, or control groups), the educational impact cannot be fully characterized, reflecting a broader trend in the literature toward narrow evaluations (eg, pre/post knowledge tests or billing metrics), underscoring the need for more comprehensive and theory-informed approaches.

Future directions include expanding the curriculum to other inpatient specialties (eg, surgery, neurology, intensive care) and adapting the structure and tools to suit their documentation patterns and code sets. Scaling the approach across departments could support institution-wide revenue integrity efforts, prompting health systems to formally integrate billing and coding education into onboarding, residency training, and ongoing professional development. Given that prior curricular efforts across specialties have demonstrated improved coding knowledge with structured instruction, this model may be adaptable across diverse learner groups and clinical contexts. At a policy and curricular level, the work suggests that core billing principles should be treated as essential competencies for inpatient clinicians, embedded longitudinally into graduate medical education and continuing education programs, and supported by EHR-integrated tools that reinforce best practices at the point of care. More broadly, this work supports a shift away from passive, lecture-based billing education toward active, case-based, and workflow-integrated models that better translate knowledge into sustained clinical practice change.

Funding Statement

None to report.