In modern medicine, there has been an increasing trend of analyzing metrics to evaluate patient outcomes, patient satisfaction, and provider productivity.
Metrics-driven performance measures have been implemented in various industries, although only recently making a frontier in medicine. Across different specialties, productivity is measured. For a hospitalist, it might be the number of admissions; for a surgeon, the number of cases; for operating room staff, the turnover time between surgical cases; or for a researcher, the number of papers published. For an emergency medicine clinician, productivity is frequently measured by patients per hour treated and the number of relative value units (RVUs) generated per hour.1 In every setting, academic or community, and by every employer, including hospitals, independent groups, or contract management groups, EM physicians’ productivity is constantly measured and compared.
For EM clinicians, there can be significant variability in productivity, depending on multiple factors such as the site of practice, staffing model, patient volume, and patient acuity.2 There is not only variation between sites, but also between providers within a site.3 Through all the factors that a clinician cannot control, the one tool that a clinician can best leverage for better productivity is appropriate charting. The metric of RVUs generated is dependent on billing and coding, which is reliant on a physician’s ability to document fully the patient encounter. In seeing the same number of patients, a clinician has the potential to generate higher RVUs if documentation accurately captures all the care that was delivered.4 Documentation at its core serves three purposes: (1) relaying important information to others, (2) a medical record to protect against liability, and (3) a tool for billing. Although during medical training residents receive ample education on the clinical and medicolegal purposes of charting, the nuances of billing are frequently mystified despite its impacts on personal compensation and financial durability of an ED.
The two main billing components that generate RVUs are the level of the patient encounter as per charting requirements and the procedures billed. A general teaching is that a high acuity ED visit should be billed at a level 4-5 (with 5 being the highest level), so long as the minimum criteria are met as described by the Centers for Medicare and Medicaid Services (CMS). Level 1-3 charts are more befitting of low acuity visits, frequently seen in urgent care settings or low acuity dedicated sections of the ED. Attention must be paid to documentation requirements as a high acuity encounter billed as a level 3 would produce approximately half of the revenue compared to a level 5 chart.5 For example, if a chest pain encounter is documented appropriately, a physician will generate more revenue from one patient encounter compared to three patient encounters with similar complaints that are charted poorly. With smarter documentation, physicians can leverage the billing and coding of their charts to maximize RVUs generated, bill accurately for services provided, and help ensure department financial stability. Without department financial stability, we risk loss of access to emergency care for many members of our community.
Common causes of underbilling in the emergency medicine encounter are inadequate documentation of procedures and “critical care” time. Two frequent errors in procedure documentation that negatively impact physician metrics, and ultimately lead to loss of ED revenue, are under-documentation of the complexity of a procedure, and failure to explicitly document a billable procedure. The loss of revenue related to critical care billing often stems from misunderstanding about the CMS billing definition of critical care time and lack of documentation of critical care time in the chart.
Complex Procedures are not so Complex
Complexity of a procedure is frequently thought by clinicians as a subjective measure of conducting the procedure, but there are CMS definitions of complexity for specific procedures. Looking at the example of a complex abscess incision and drainage (I&D) versus a simple abscess I&D, CMS describes an I&D as complex if the abscess was probed or loculations were broken up during the procedure, if there were multiple abscesses, or if it was packed.6 Probing and breaking up loculations are fundamentals of an emergency department I&D, making nearly all abscess I&Ds completed in the ED complex per the CMS definition. The implication of documenting simple I&Ds, which generate 2.77 RVUs, instead of complex I&Ds that bill 5.12 RVUs, is the loss of tens of thousands of dollars in revenue for a department annually.7 Similarly, laceration repairs are coded by the length of the laceration. Lacerations less than 2.5 cm generate 1.27 RVUs, while those greater than 2.5 cm generate 1.67 RVUs or more.8 Although it might not be general practice to measure exact wound size with a ruler, an easy way to accurately estimate wound length is by the number of sutures used. Traditionally, sutures are placed 0.5 cm apart, so one can estimate that the laceration size must be greater than 2.5 cm when more than four sutures are placed in one layer. It is also worth noting that when performing laceration repairs, using a skin-adhesive or steri-strips in place of sutures still counts as a laceration repair and should be documented as such. It is important for ED physicians to learn about these details in procedural documentation, so that there is accurate compensation for their work.
Missed Opportunities in Documenting Billable Procedures
Another frequent cause of underbilling is not separately documenting all billable procedures. Although we are usually immaculate in placing procedure notes for things such as endotracheal intubations and central lines, many physicians fail to recognize that procedures such as cardiopulmonary resuscitation (CPR) and cardioversions can be billed separately. Thus, along with critical care time charted (although this cannot include time spent on separately billed procedures), we can bill for CPR, which significantly increases RVUs generated from the patient encounter, leads to increased departmental revenue, and more accurately represents the care delivered. One way to make procedural documentation easier is by leveraging the Electronic Medical Record (EMR) to make dot-phrases or saved dictation texts. These tools are shortcuts to longer documentation and can ensure that any procedure can be documented efficiently. When documenting a patient encounter, we merely have to say a phrase like “insert CPR” or type “.cpr” to prefill a procedure note and adjust accordingly for a specific patient encounter.
Understanding Critical Care Time
Underbilling related to critical care time documentation often stems from the difference in how EM physicians think about critical care compared to the actual CMS billing criteria for “critical care.” EM physicians frequently use subjective measures of hemodynamic instability or obvious immediate life-threatening illness to determine when to bill for critical care time, which can lead to severe underbilling of care provided. CMS defines critical care time as care for a patient with a “high probability of imminent or life-threatening deterioration” or illness that “impairs one or more vital organ systems,” requiring “frequent personal assessment and/or manipulation.” This definition and coding system is used for all providers through the healthcare system and is not specific to emergency medicine. Many diagnoses and clinical conditions that EM physicians manage and treat on a regular basis do not meet our intrinsic threshold to be considered “critical,” but they often are based on the definition by CMS. For example, any use of non-invasive ventilation (BiPAP or CPAP) infers a patient is in a critical state, and charting critical care time should be considered. Other common missed opportunities to document critical care time include hyperkalemia management that requires a corrective measure such as calcium. Hypoglycemia that needs dextrose administration with three finger stick glucose checks throughout the patient’s ED course can also be considered for critical care time. There are numerous such examples of underbilled critical care time as per the CMS definition, leading to loss of revenue for emergency departments. Becoming familiar with diagnoses and intervention requirements that consist of critical care time can be immensely worthwhile to ensure that the RVUs generated from a patient encounter accurately reflect the care we provide.
By knowing the minimum criteria for charting accurately, EM physicians can more reliably get credit and compensation for the care they deliver. Using the tips of documentation described above, residents can ensure that after graduating they are capturing high RVUs to maximize their measured productivity. In many employee contracts, compensation is linked to metrics recorded for an individual clinician, so RVUs generated can significantly impact a clinician’s salary. For example, salary variability could range between $250,000 to $400,000 for a provider, with the ultimate decision dependent on metrics such as RVUs. By knowing how to bill appropriately, physicians can ensure that the metrics reflect the care provided AND increase revenue generated for the ED. Most importantly, increased revenue for the department allows us to be financially viable and better prepared to increase care capacity. Additional resources enable departments to hire more providers, fund more projects, and acquire the latest technology, which ultimately improves the care we provide and increases access to emergency care for members of our communities.
- “Complex” billed procedures aren’t so complex. “Critical care” time billed isn’t always what we think of as critical.
- Remember to recognize and document all billable procedures.
- Maximizing RVUs generated allows us to continue delivering emergency care to patients who need it most.
- Foster K, Penninti P, Shang J, Kekre S, Hegde G, Venkat A. Leveraging Big Data to Balance New Key Performance Indicators in Emergency Physician Management Networks. Prod Oper Manag. 2018;27:1795-1815.
- Stenson B, Anderson J, Davis S. Staffing and Provider Productivity in the Emergency Department. Emergency Medicine Clinics of North America. 2020;38(3):589-605.
- Joseph JW, Davis S, Wilker EH, et al. Modelling attending physician productivity in the emergency department: a multicentre study. Emergency Medicine Journal. 2018;35:317-322.
- Powell A, Savin S, Savva N. Physician Workload and Hospital Reimbursement: Overworked Physicians Generate Less Revenue per Patient. Manufacturing & Service Operations Management. 2012;14(4):512-528.
- Work RVU Calculator. Available at: https://www.aapc.com/practice-management/rvu-calculator.aspx. Accessed December 20, 2021.
- Magdziarz, D. High-Yield RVU Generation in Emergency Medicine. 2021. Available at: https://epmonthly.com/article/high-yield-rvu-generation-in-emergency-medicine/. Accessed January 5, 2022.
- Adler, J. Documentation Pearls for Navigating Abscess Incision/Drainage Codes. 2016. Available at: https://www.acepnow.com/article/documentation-pearls-for-navigating-abscess-incisiondrainage-icd-10-codes/. Accessed November 30, 2021.
- Top 20 ED Reimbursement Codes. 2016. Available at: https://www.acep.org/administration/reimbursement/top-20-ed-reimbursement-codes/. Accessed January 5, 2022.