Does the use of standardized history and physical forms improve billable income and resident physician awareness of billing codes?

Objectives: Resident physician knowledge of financial reimbursement guidelines for patient encounters is limited. We determined whether the use of standardized history and physical examination forms by residents for hospital admissions plus a brief lecture would increase the level of billing codes, increase billable income, and increase resident awareness of billing guidelines.

Methods: Residents used history and physical examination forms after a brief documentation lecture. Pretrial and posttrial surveys measured awareness of billing guidelines. The admission billing codes for a 6-month period were obtained, and the percentages were compared with a control 6-month period.

Results: There was an absolute increase of 14.5% in the highest code between the two study periods (P < 0.0001). Billable income increased by $10,385. Resident documentation awareness also increased (P < 0.001).

Conclusions: The use of history and physical examination forms, combined with a brief lecture, significantly increased the percentage of highest billing codes, which increased billable income. Resident awareness of documentation requirements significantly improved.

Key Words: financial management, graduate medical education, hospital, internship and residency 

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The Centers for Medicare and Medicaid Services (CMS), formally known as the Health Care Financing Administration, has established billing guidelines for physicians. These guidelines have resulted in the Current Procedural Terminology and Evaluation and Management (E/M) codes that determine reimbursement based on the complexity of patient problems and services rendered. To meet the highest appropriate level of billing, CMS requires a certain level of documentation. The Office of the Inspector General of the Department of Health and Human Services enforces CMS guidelines through the use of audits.

Documentation has become increasingly important in the last several years as institutions struggle to comply with CMS regulations. Institutions that have failed to meet such requirements have suffered great financial expense. The University of Pennsylvania in 1995, for example, settled with the US government for $30 million in repayments and penalties for the inappropriate billing of Medicare patients. Shortly thereafter, Jefferson Faculty Foundation at Thomas Jefferson University was penalized with $12 million in repayments and fines for similar offenses. (1) In addition, individual physicians are at risk for civil penalties for upcoding claims. This may result in fines up to triple the amount claimed but not less than $5,000 and not more than $10,000 for each claim filed. (2) It is therefore of utmost importance that physicians and their institutions understand and meet these government regulations.

Sufficient documentation is not only necessary to ensure compliance, but it plays an indispensable financial role. Inadequate documentation results in "downcoding" and thus a substantial loss of billable income. Institutions have tried various methods to rectify this problem, including the use of standardized history and physical (H & P) forms to improve documentation, billing codes, and revenue generation. A study from the Department of Emergency Medicine, Texas Tech University, found that the use of T-system template forms based on a patient's chief complaint increased their coding levels, resulting in higher total gross billing. (3) A study from the Department of Emergency Medicine at Maine Medical Center in Portland found that the use of pocket-sized dictation templates along with Continuous Quality Improvement methodology not only increased compliance with guidelines but also decreased the downcoding of charts and increased billable records. (4) The Burn Unit at the Ohio State University Hospital instituted a standardized computerized H & P template and found that they substantially increased their billable income. (5)

Despite the increasing level of importance of documentation and billing, physician knowledge is lacking. For example, a study conducted to evaluate Emergency Medicine resident physicians' knowledge of billing codes showed that 84% did not know the emergency physician charges for the various levels of service. (6) To rectify this, some institutions have developed specialized educational programs. Educational programs for faculty physicians have been shown to not only increase compliance but also improve documentation. Improved documentation results in higher levels of billing codes, which translates into increased revenue. The University of St Louis developed an intense educational program that resulted in an increase in the gross collection rate (as a percentage of the total gross charges the hospital collected) for the Department of Internal Medicine. (7) The Department of Family Medicine at Wayne State University School of Medicine developed a similar type of curriculum and found that after implementation, their billing errors were significantly reduced, the number of overcoded and undercoded charts decreased, and the number of other billing errors decreased. (8)

The documentation requirements of residents in teaching settings are unique. The teaching physician must only document that he or she was present during the critical or key portion(s) of the service that was performed and was directly involved in the treatment of the patient. The resident's note typically contains the majority of the E/M documentation for the appropriate level of service. For payment, the composite of the teaching physician and resident physician note together must support the medical necessity and level of service billed by the teaching physician. (9) In this teaching physician-resident partnership, proper documentation by residents is the driving force for the appropriate level of service that is billed. It is therefore crucial that residents understand and comply with E/M documentation requirements. Furthermore, the Accreditation Council for Graduate Medical Education (ACGME) has recently established six competencies and has required residents to become proficient in each one. One of these is the "Systems-Based Practice" competency, defined as "actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value." (10) Many residency programs find this difficult to incorporate and assess.

With the complexity of CMS guidelines, it is difficult for residents to remember what details to document to meet the highest appropriate billing codes. To our knowledge, there have been few studies that have evaluated the ability of standardized H & P forms to improve residents' awareness of and compliance with CMS guidelines and to increase the level of billing codes. We created a standardized H & P form for general internal medicine inpatient admissions with standardized dictation templates to improve the aforementioned. The use of these forms with quick check boxes was proposed to serve as a template for residents to increase their efficiency without the need for lengthy handwritten notes. This was hypothesized to (1) increase the level of billing codes, (2) improve billable income, and (3) increase resident awareness of CMS documentation requirements.

Materials and Methods

A standardized H & P form was created using Microsoft Publisher and used by first-, second-, and third-year residents for general internal medicine admissions at Gundersen Lutheran Medical Center between July 1 and December 31, 2002. The form was four pages in length and included prompts to remind residents which necessary items to include in the history of present illness, past medical history, family history, social history, review of systems, physical examination, and assessment and plan sections. It also featured check boxes in the review of systems and physical examination sections for ease of documentation. Admission billing codes 99221, 99222, and 99223 were evaluated, with 99223 representing the highest billing code. Critical care billing codes were excluded. Only charts in which a resident documented the H & P were evaluated. The number of 99221, 99222, and 99223 billing codes generated during July 1 through December 31, 2002 were determined. The percentages of each code were calculated and compared with the percentages of 99221, 99222, and 99223 codes from July 1 through December 31, 2001, 1 year before any formal documentation lecture or use of H & P forms. These dates were selected because in July the new first year residents began their training. They lack the experience of upper level residents who have had several months of on-the-job training. This was intended to help lessen the learning curve bias by not comparing new residents' first 6 months with their last 6 months. The number of second- and third-year residents was similar in each time period. The residents were blinded to the billing code level generated for each admission, as our institution employs seven inpatient E/M coders who determine the proper code for the services, based on documentation and medical necessity. There was no feedback provided by the E/M coders as to actual billing codes for admissions. This system ensured that the residents were unaware of the billing code level generated by their documentation. The same seven individual E/M coders remained constant throughout, from July 1, 2001, to December 31, 2002.

The percentages of 99221, 99222, and 99223 codes for each period were analyzed for statistical significance, using [chi square]. A value of P < 0.05 was considered statistically significant. Billable income for each period was determined by using 2002 fees for each of the codes at our institution. Fees were as follows: 99221 = $283.30; 99222 = $329.90; and 99223 = $396.70. The fraction of each code used in the 2001 study period was multiplied by the total number of admissions in the 2002 study period. The 2002 fees were then applied. This negated the difference in number of admissions between the study periods and allowed the total billable income difference to be directly compared.

All residents who were scheduled to rotate on the General Medicine service in the next 6 months filled out a pretrial survey on July 1, 2002, that consisted of seven questions pertaining to their awareness of billing codes (Table 1). Each question was answered with a number 1 through 5. A number 1 indicated that the resident strongly disagreed with the statement, 2 indicated disagreement, 3 indicated neutrality, 4 indicated agreement, and 5 indicated strong agreement. They received instruction on the use of the standardized H & P form and information regarding the level of documentation needed to achieve the appropriate highest billing codes during a 30-minute lecture. At the end of the study, the same residents were asked to complete a posttrial survey that consisted of the same seven questions in the pretrial survey, plus two additional questions (Table 2). The first seven questions of the pretrial and posttrial surveys were analyzed for statistical significance, using the t test and SAS software. A value of P < 0.05 was considered to be statistically significant.

Results

Thirty-three residents participated in the study, with 23 being first-year residents. Table 3 shows the results of the billing codes obtained between July 1 and December 31, 2001, compared with the same months in 2002. There were 708 admissions done by residents during the 6-month study period in 2001 compared with 848 in 2002. The percentage of the highest billing code, 99223, increased from 78.7% in 2001 to 93.2% in 2002, giving an absolute increase of 14.5% (P < 0.001).

Billable income for all billing codes in 2001 was $320,510.72 and in 2002 was $330,896.20, leading to an increase of $10,385.48 in billable income.

Table 4 displays the results of the resident survey (n = 31 for the pretrial survey and n = 33 for the posttrial survey). Two pretrial surveys were excluded from the analysis. One was excluded because the resident was not available for the entire 30-minute teaching session. The other was excluded because the resident filled out the entire survey incorrectly. On the posttrial survey, seven surveys were partially filled out either incompletely or incorrectly. The residents' awareness of their documentation improved in each category of the H & P (P < 0.001), in their perceived adequacy of their documentation (P < 0.001), and perceived efficiency (P < 0.005). There was no significant change in their perception of the amount of time spent with documentation.

Discussion

Knowledge of billing and reimbursement is becoming an important issue for physicians. This is not only true when caring for Medicare patients but also for patients with private insurance. Residents are often inadequately instructed on the intricacies of billing. As Medicare reimbursement continues to be threatened, it will become increasingly important for all physicians to have a solid understanding of billing so that these patients do not become an increasing financial strain on their practice. If reimbursement continues to be reduced, physicians may need to limit the number of Medicare patients they serve or face economic hardship.

A standardized H & P form can be used as a tool by residents to help increase billable income for their respective institutions. Our data suggest that these forms helped our residents increase the completeness of their documentation. Implementation of these forms also showed a statistically significant increase in the use of the highest billing code (99223). This translated into an increase of more than $10,000 in billable income for one specialty over a 6-month period. We had a relatively high percentage of 99223 codes during our baseline study period in 2001 (78.7%), which made it difficult to show a more extensive improvement. The billable income difference would have been more significant had we started with a lower percentage of 99223 codes, which may be the case in other specialties and/or other institutions. A potential weakness of this study is the possibility of differences in patient characteristics and disease severity in each study period. Even though our patient population is very homogenous and stable, this could be a source of error.

There were also statistically significant increases in residents' awareness of all sections of the H & P, adequacy of documentation, and efficiency. There was no objective testing of the residents to determine whether their actual knowledge increased. However, this is suggested, as the fraction of 99223 codes increased between the two study periods. Overall, our residents still thought that they spent too much time with documentation. However, as a whole, they thought that their efficiency increased.

This study also addresses a unique way to implement the recent ACGME "Systems-Based Practice" competency. This competency is sometimes difficult for residents to understand and for faculty physicians to effectively teach. Our study proved useful in helping to develop resident proficiency in this important competency.

If applied in other specialties and/or at other institutions, standardized H & P forms and educational sessions teaching CMS guidelines could have several positive implications. First, it would increase compliance with CMS regulations as well as decrease inappropriate billing that may result in penalties for individuals and institutions. Second, the potential appropriate increase in the level of billing codes could mean millions of dollars per year in increased reimbursement for hospitals, if applied nationally. Third, if certain hospitals do not require dictation of the H & P, forms such as this could significantly reduce transcription costs. Fourth, as physician knowledge of CMS guidelines and the use of standardized H & P forms become more widespread, the application of knowledge of inpatient guidelines to outpatient clinics and other patient service venues could lead to significant increases in nonhospital reimbursement.

Conclusion

We believe that a standardized H & P form can be used as a tool to help residents improve their level of documentation and therefore billable income that they generate for their respective institutions. Also, these forms can help ensure that residents remain compliant with CMS guidelines. In addition, this appears to be an effective way to teach a portion of the ACGME "Systems-Based Practice" competency.

Table 1. Pretrial and posttrial survey questions (a)

No.                          Question

1    In general, I know the CMS documentation requirements for
     maximum billing purposes in the History of Present Illness section
     of my History and Physical.
2    In general, I know the CMS documentation requirements for
     maximum billing purposes in the Past/Family/Social History section
     of my History and Physical.
3    In general, I know the CMS documentation requirements for
     maximum billing purposes in the Review of System section of my
     History and Physical.
4    In general, I know the CMS documentation requirements for
     maximum billing purposes in the Physical Examination section of
     my History and Physical.
5    In general, I feel my overall level of documentation is adequate
     for maximum billing purposes as specified by CMS guidelines.
6    In general, I am efficient in performing a complete History and
     Physical along with required documentation and dictation.
7    In general, I spend too much time with documentation.

(a) CMS, Centers for Medicare and Medicaid Services.

Table 2. Posttrial additional survey questions

No.                          Question

1    The History and Physical forms are user-friendly.
2    The use of the History and Physical forms made me more
     conscious of the amount of documentation needed for maximum
     billing purposes.

Table 3. Percentage of billing codes in each study period

Billing  July-December  July-December
code     2001 (n)       2002 (n)

99221      9.9% (70)      4.1% (35)
99222     11.4% (81)      2.7% (23)
99223     78.7% (557)    93.2% (790) (P < 0.001)
Total    100% (708)     100% (848)

Table 4. Survey results for residents (a,b)

                            Pretrial     Posttrial
Category                      (SD)         (SD)       P

Months on GM Service        2.23 (3.34)  4.21 (3.47)  <0.001
Knowledge of HPI            2.27 (1.31)  3.87 (0.76)  <0.001
Knowledge of PMH/FH/SH      1.97 (1.22)  3.94 (0.85)  <0.001
Knowledge of ROS            2.17 (1.42)  4.00 (0.88)  <0.001
Knowledge of PE             2.20 (1.27)  3.97 (0.87)  <0.001
Adequacy of Documentation   2.07 (1.17)  3.65 (0.91)  <0.001
Perceived Efficiency        2.63 (1.10)  3.74 (0.93)  <0.005
Time with Documentation     3.57 (1.10)  3.97 (1.00)   NS
User-friendly                            4.17 (1.05)   N/A
Documentation Awareness                  4.34 (1.01)   N/A

(a) GM, General Medicine; HPI, History of Present Illness; PMH, Past
Medical History; FH, Family History; SH, Social History; ROS, Review of
Systems; PE, Physical Examination.
(b) Pretrial, n = 31: posttrial, n = 33: 1 = strongly disagree; 2 =
disagree; 3 = neutral; 4 = agree; 5 = strongly agree.

Acknowledgments

The authors thank Ann Bina for help with data collection and Michelle Mathiason for statistical calculations.

Accepted October 4, 2004.

References

1. Cohen JJ, Dickler RM. Auditing the Medicare billing practices of teaching physicians: welcome accountability, unfair approach. N Engl J Med 1997;336:1317-1320.

2. Hart R, Sheidy D. Building a compliance program. Med Group Manage J 1998;45:17-22.

3. Marill KA, Gauharou ES, Nelson BK, et al. Prospective, randomized trial of template-assisted versus undirected written recording of physician records in the emergency department. Ann Emerg Med 1999;33:500-509.

4. Higgins GL, Becker MH. A continuous quality improvement approach to IL-372 documentation compliance in an academic emergency department, and its impact on dictation costs, billing practices, and average patient length of stay. Acad Emerg Med 2000;7:269-275.

5. Heistein JB, Coffey RA, Buchele BA, et al. Development and initiation of computer generated documentation for burn patient care. J Burn Care Rehabil 2002;23:273-279.

6. Howell J, Chisholm C, Clark A, et al. Emergency medicine resident documentation: result of the 1999 American Board of Emergency Medicine In-Training Examination Survey. Acad Emerg Med 2000;10:1135-1138.

7. Miller DD, Getsey CL. Impact of a compliance program for billing on internal medicine faculty's documentation practices and productivity. Acad Med 2001;76:266-272.

8. Rose EA, Roth LM, Werner PT, et al. Using faculty development to solve a problem of evaluation and management coding: a case study. Acad Med 2000;75:331-336.

9. Medicare Carriers Manual. Section 15016. Supervision Physicians in Teaching Settings. <http://www.cms.hhs.gov/manuals/pm_trans/R1780B3.pdf>. Accessed 2/4/04.

10. Accreditation Council for Graduate Medical Education Competencies. <http://www.acgme.org/DutyHours/dutyHoursCommonPR.pdf>. Accessed February 5, 2004.

RELATED ARTICLE: Key Points

* The documentation requirements of resident physicians in teaching settings are important and unique.

* A standardized history and physical form can be used as a tool by residents to help increase billable income for their institution.

* This form can also be used to increase resident awareness of documentation requirements.

Scott J. Sprtel, MD, and Jonathan A. Zlabek, MD

From the Department of Internal Medicine, Gundersen Lutheran Medical Center, La Crosse, WI.

Reprint requests to Jonathan A. Zlabek, MD, 1900 South Avenue, La Crosse, WI 54601-5494. Email: [e-mail]