Differences in evaluation and management coding of outpatient clinic visits for patients undergoing elective spine surgery with use of a standardized template.

Autor:	Yen TC; Department of Orthopaedic Surgery, University of Missouri-Columbia, Columbia, MO, USA., Oladeji L; Department of Orthopaedic Surgery, University of Missouri-Columbia, Columbia, MO, USA., Moon M; Department of Orthopaedic Surgery, University of Missouri-Columbia, Columbia, MO, USA., Troyer L; Department of Orthopaedic Surgery, University of Missouri-Columbia, Columbia, MO, USA., Bradford T; Department of Orthopaedic Surgery, University of Missouri-Columbia, Columbia, MO, USA., Harris S; Department of Orthopaedic Surgery, University of Missouri-Columbia, Columbia, MO, USA., Knoth J; Department of Orthopaedic Surgery, University of Missouri-Columbia, Columbia, MO, USA., Rawat S; Department of Orthopaedic Surgery, University of Missouri-Columbia, Columbia, MO, USA., Choma TJ; Department of Orthopaedic Surgery, University of Missouri-Columbia, Columbia, MO, USA., Moore DK; Department of Orthopaedic Surgery, University of Missouri-Columbia, Columbia, MO, USA.
Jazyk:	angličtina
Zdroj:	Journal of spine surgery (Hong Kong) [J Spine Surg] 2023 Jun 30; Vol. 9 (2), pp. 117-122. Date of Electronic Publication: 2023 Apr 10.
DOI:	10.21037/jss-22-91
Abstrakt:	Background: In a large teaching institution with providers of various levels of training and backgrounds, and a coding department responsible for all evaluation and management (E&M) billing, variations in documentation can hinder accurate medical management and compensation. The purpose of this study is to assess differences in re-imbursement between templated and non-templated outpatient documentation for patients who eventually underwent single level lumbar microdiscectomy and anterior cervical discectomy and fusion (ACDF) both before and after the E&M billing changes were implemented in 2021. Methods: Data was collected from three spine surgeons on 41 patients who underwent a single level lumbar microdiscectomy at a tertiary care center from July 2018 to June 2019 and 35 patients seen by four spine surgeons from January through December of 2021 given the new E&M billing changes. ACDF data was collected for 52 patients between 2018 and 2019 for three spine surgeons and 30 patients from January through December of 2021 from four spine surgeons. Billing level was decided by independent coders for preoperative visits. Results: During the study period from 2018-2019 for lumbar microdiscectomy, each surgeon averaged about 14 patients. Results showed variability of billing level between the three spine surgeons (surgeon 1, 3.2±0.4; surgeon 2, 3.5±0.6; and surgeon 3, 2.9±0.8). Interestingly, even after the implementation of the 2021 E&M billing changes, there was a statistically significant increased level of billing for templated notes for lumbar microdiscectomy (P=0.013). However, this did not translate to the clinic visits for patients who underwent ACDF in 2021. When data was aggregated for all the patients from 2021 who either underwent lumbar microdiscectomy or ACDF, using a template still resulted in a statistically significant higher level of billing (P<0.05). Conclusions: Utilization of templates for clinical documentation reduces variability in billing codes. This impacts subsequent reimbursements and potentially prevents significant financial losses at large tertiary care facilities. Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-22-91/coif). The authors have no conflicts of interest to declare. (2023 Journal of Spine Surgery. All rights reserved.)
Databáze:	MEDLINE
Externí odkaz:	Zobrazit plný text záznamu