Children meeting Centers for Medicare and Medicaid Services (CMS) criteria for critical care billing are often cared for by pediatric hospital medicine (PHM) teams outside the intensive care unit (ICU). Current CMS guidance allows for billing of critical care codes outside of an ICU. These codes have substantially higher relative value units (RVU) attached to them and reimburse at higher rates than the usual evaluation and management (E&M) codes.1 Several efforts to optimize use of critical care billing has been described in emergency medicine literature, although few efforts have been described with hospitalists.2–4
In this issue of Hospital Pediatrics, Ramazani and colleagues report a quality improvement initiative to increase the frequency of critical care billing codes on eligible patients on the PHM service.5 To capture a population that reliably meets CMS criteria for critical care billing, the authors examined daily attending billing encounters on children aged 0 to 18 years receiving either at least 5 L high-flow nasal cannula oxygen or continuous albuterol. Encounters without a daily E&M code or with a bill from an advanced practice provider were excluded. The primary outcome was the percentage of critical care codes selected in eligible patients. The secondary outcome was the number of billed RVUs in those encounters with local estimation of professional reimbursement, as compared with standard high-level E&M codes and reimbursement to assess financial impact. The process measure was defined as the percentage of documented clinical encounters meeting eligibility criteria in which documentation supported the use of critical care codes. The balancing measure was defined as the number of insurance denials. Iterative Plan-Do-Study-Act cycles tested and implemented interventions, including divisional education, audits of documentation, and electronic medical record (EMR) supports, to standardize billing practices and provide real-time guidance regarding critical care billing opportunities. The impact of interventions was followed prospectively with statistical process control charts.
From November 2023 to April 2024 the interventions described were associated with an increase in the usage of critical care codes from 21% to 74% while demonstrating special cause variation. This increase was sustained for 4 months. They also found an upward shift in the number of documented clinical encounters containing documentation that met criteria for critical care billing, which was also sustained past their initial study period. The authors meanwhile found a 3-fold increase in the number of RVUs collected and a 4-fold estimated increase in reimbursement relative to noncritical care billing efforts. Finally, the authors observed exceedingly few (<1%) denials of critical care charges relative to the total number of charges during their study period.
Strengths and Limitations
This single-center quality improvement effort has some lessons for other hospitalist programs seeking to increase the adoption of appropriate critical care billing practices. This work built on previous efforts4 by leveraging a multilayered approach, including a multidisciplinary team spanning PHM, critical care, and billing professionals, targeted provider education, and creative EMR decision support. The EMR-based interventions in particular held a high level of reliability, and similar interventions have previously demonstrated effectiveness.6
We commend the decision to include a pediatric critical care physician in the standardized use of global critical care codes (billed once daily)7 vs time-based codes (available for more than one physician to use). This proactive approach minimized any potential conflict over ownership of those global codes, and PHM physicians planning their own efforts to enhance critical care billing should highly consider similar partnerships.
An additional strength of this study is the chosen balancing measure: insurance denials. Initial monitoring of denials showed that duplicate use of global critical care codes was an easily modifiable cause of denials. Providing guidance as to when time-based codes should be used as opposed to global codes made denials exceedingly rare. This work should thus give confidence to hospitalists that they will not negatively impact the financial performance of their group nor their colleagues in intensive care when functioning within the guidance.
Although we have no doubt that other centers can boost reimbursement with an effort to appropriately bill for critical care services, the calculated benefit as defined in the secondary outcome is highly specific to the study hospital, and other hospitalist groups will need to calculate their financial impact based on different payer mix and contractual reimbursement rates.
For this effort, the authors chose 2 inclusion criteria: any high-flow oxygen greater than 5 L/min and continuous albuterol. We imagine that the high flow amount was chosen based on the ease of pulling data from the EMR. Since bronchiolitis is the most common evidence-based8 indication for high-flow oxygen in infants and it is dosed by weight, a weight-based rate (eg, >1 mL/kg/min) and/or a higher threshold may have been more useful in defining a population that would clearly meet critical care criteria. The authors accounted for this issue by setting a lower improvement target for critical care code use. If a weight-based threshold is possible, a higher target may be appropriate. Other centers may also wish to broaden the target population to include other common diagnoses for which critical care provision is appropriate, such as sepsis, status epilepticus when needing active intervention, and severe electrolyte abnormalities including diabetic ketoacidosis.3
An additional limitation is the duration of measurement—the study authors monitored performance for 4 months following active interventions. A longer period (12 months or longer) would provide a better assessment of long-term sustainability and whether additional interventions are needed to maintain impact.
Financial Implications
Being able to increase the proportion of critical care billing has significant financial implications for the individual hospitalist via productivity incentives, as well as for overall hospital medicine program sustainability. For programs, increasing RVUs and professional fee reimbursement per encounter may be helpful in both demonstrating the value of existing resources and justifying additional resources to meet clinical demands. In particular, additional billing revenue may help cover the expenses of less lucrative clinical services, such as surgical comanagement or overnight care, that are essential to patient safety and high-quality care.9,10 In addition, appropriate documentation to support critical care billing has important implications for children’s hospital billing, reimbursement, and financial sustainability. Michelson and colleagues recently described a nearly 30% decrease in nationwide pediatric bed capacity from 2008 to 2018.11 In efforts to accurately document evidence of a critical illness where “one or more vital organ systems are acutely impaired,”5,7 physicians will need to document diagnoses such as status asthmaticus, septic shock, and/or acute hypoxic respiratory failure, which the authors skillfully facilitate with their EMR template.5 While helping to justify critical care professional codes, these diagnoses can be coded to higher-acuity diagnostic-related groups, likely enhancing hospital reimbursement, as well, with payers that reimburse on an acuity- or value-based system.12
Finally, there are patient-level benefits, including the accurate description of the severity of a child’s illness improving communication between providers, as well as demonstrating the ongoing justification of inpatient care.
Given the numerous benefits, we recommend that hospitalists and PHM programs consider their own opportunities for improving the accuracy of their professional billing for critical care services.
Dr Scalici conceptualized the work, drafted the initial manuscript, reviewed revisions, and approved the final manuscript as submitted. Dr Shaughnessy conceptualized the work; reviewed, added to, and revised the manuscript, and approved the final manuscript as submitted.
CONFLICT OF INTEREST DISCLOSURE: The authors have no conflicts of interest relevant to this article to disclose.
FUNDING: No funding was used for this work.
COMPANION PAPER: A companion to this article can be found online at www.hosppeds.org/cgi/doi/10.1542/hpeds.2024-008183.
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