Background and objective: As more critically ill patients are managed by pediatric hospital medicine (PHM), accurately capturing the services provided and corresponding reimbursement is essential for pediatric hospitalists. We sought to increase the proportion of critical care codes billed in eligible critically ill PHM patients from a baseline mean of 21% to more than 50% over 6 months.
Methods: A quality improvement (QI) initiative was conducted at a tertiary care children's hospital on the PHM service from November 2023 through April 2024. Eligibility for critical care billing was determined by the Centers for Medicaid and Medicare Services definition and applied to patients requiring at least 5 L of high-flow nasal cannula or continuous albuterol on attending physician evaluation (n = 380). Key drivers included clinician knowledge of critical care billing, the application of standardized definitions, appropriate documentation, and clinician billing practices. The outcome measure was the percentage of critical care codes billed in eligible critically ill patients, and the process measure was the percentage of charts containing documentation to support critical care billing.
Results: The mean percentage of critical care codes increased from 21% to 74%, with special cause variation observed. This led to a 3-fold increase in relative value units (RVUs) and a 4-fold increase in the total estimated reimbursement generated. The mean percentage of charts with documentation to support critical care billing increased from 31% to 70%.
Conclusions: A QI initiative to systematically implement critical care billing in eligible PHM patients was associated with an improvement in critical care billing and documentation, significantly increasing RVUs and reimbursement.
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