A fiscally sound,evidenced-based solution to conquering the complexity of physician billing guidelines: A physician-centric note template

Abstract

Background: Effective documentation and coding in health care are crucial for patient care, safety, workflow improvement and accurate billing. Objectives: This quality improvement study aimed to enhance History and Physical (H&P) note documentation and charge capture processes to integrate coding and billing aspects, capture authentic work, preserve the H&P’s integrity and align H&P-related revenue with actual performance. Method: A multidisciplinary team, including divisional leadership and specialists in documentation improvement, electronic health records, lean/six sigma methodology, a nocturnist and a senior-level physician coding auditor, initiated a quality improvement project. Educational efforts targeted approximately 50 hospitalists at a Departmental meeting in January 2023 (Department of Medicine, University of North Carolina School of Medicine), followed by the development and iterative testing of a standardised H&P note template in March 2023, officially disseminated to the entire Department in June 2023. Results: Despite limited impact from education alone, the implementation of an updated H&P template in May 2023 and department-wide distribution in June led to an immediate increase in average work relative value units (wRVU) per encounter, driven by enhanced capture of prolonged time codes and key medical decision-making phrases. The sustained correlation between template usage and increased wRVUs demonstrated a consistent, elevated plateau compared to the education phase. Conclusion: Collaboratively designed and user-informed note templates, balancing usability, efficiency and revenue-generating elements, proved more effective than education alone in integrating complex changes into clinical practice and enhancing coding and billing accuracy. Implications: Results of this study underscore the benefits of standardised documentation tools in enhancing both clinical and financial outcomes, suggesting that healthcare institutions could improve revenue capture, and documentation accuracy by adopting similar approaches.