September 3, 2021

Improving Clinical Documentation in Vascular Surgery Increases Reimbursement and Quality Alike

Study argues for expanded role for advanced practice providers

21-HVI-2255658_clinical-documentation-and-quality_650x450

An initiative to improve documentation of evaluation and management (E/M) services and subsequent hospital care by advanced-practice providers (APPs) on Cleveland Clinic inpatient vascular surgery teams resulted in substantial improvements in reimbursement, accuracy of patient complexity measurements and quality of care.

Advertisement

Cleveland Clinic is a non-profit academic medical center. Advertising on our site helps support our mission. We do not endorse non-Cleveland Clinic products or services. Policy

So finds a new analysis published by Cleveland Clinic researchers in the Journal of Vascular Surgery (Epub 2021 Jun 26). The study is the first to examine the impact of APPs billing outside the global surgical package, i.e, a single payment for all care associated with a surgical procedure.

“Specific and accurate documentation of patient care and diagnoses in the medical record are essential to demonstrate high-quality care and to determine appropriate reimbursement,” says study co-author Sean Lyden, MD, Chair of Vascular Surgery at Cleveland Clinic.

“As surgeons,” he adds, “we cannot bill outside the global surgical package for inpatient care, but APPs can for preexisting conditions. Vascular surgery patients tend to have many serious comorbidities that exist prior to admission and these conditions need to be managed in the perioperative period, complicating surgical care. Functioning as independent practitioners, APPs provide complex medical management for these comorbidities and may bill for their services.”

Rationale for the initiative

Prior to the documentation initiative, the vascular surgery team would see patients and document notes in the chart but not necessarily code for all the complicating comorbid conditions of this challenging population. “There has always been a lot of misunderstanding nationally about documentation, coding and billing,” Dr. Lyden explains. “We sought to correct this in our department and our institute with accurate and careful documentation.”

In 2016, Cleveland Clinic’s Heart, Vascular & Thoracic Institute undertook the initiative to ensure that E/M notes were thoroughly completed for all patients, including those in the Department of Vascular Surgery.

Standardized documentation templates were developed with assistance from the institute’s coding and documentation specialists and made available in Cleveland Clinic’s electronic medical record. A daily progress note was created to increase the accuracy of documentation relative to Centers for Medicare & Medicaid Services (CMS) reimbursement guidelines. The note was designed to automatically populate key elements to be reviewed and amended by practitioners.

Advertisement

All APPs and staff surgeons were provided with comprehensive training in the new documentation procedures.

Impact on charges and reimbursement

To evaluate the impact of improved documentation on reimbursement and quality metrics, hospital care E/M codes from 2015 to 2017 were audited and analyzed.

One year after the documentation initiative began, E/M charges on the vascular surgery service line had increased by 78.5%, with a parallel increase in APP charges from 0.4% of billable E/M services to 70.4%. Charge capture of E/M services for all vascular surgery inpatients climbed from 21.4% to 37.9%. Reimbursement by CMS increased accordingly, by 65.0%.

Impact on quality metrics

In addition to increased reimbursement, better E/M documentation provided a more accurate view of quality and complexity of care.

“Inpatient acuity is critical in determining quality metrics and ensuring the accuracy of publicly reported data,” Dr. Lyden explains. “When we do not code and bill properly, we do not provide a fair picture of patient acuity and complexity which are typically very high in vascular surgery patients, especially at Cleveland Clinic.”

For example, if a patient is documented only as having had an aneurysm, that is considered far less complex than if it’s noted that they also had a history of coronary and carotid surgery, hypertension, hyperlipidemia and other comorbidities. “If a patient without documented comorbidities passes away,” Dr. Lyden notes, “it is considered an unexpected death, whereas morbidity and mortality in a patient with a large juxtarenal aortic aneurysm with multiple comorbidities might be more expected.”

Advertisement

Two publicly reported quality metrics, the case mix index (CMI) and the mortality index (MI), depend on the accuracy of inpatient documentation and impact quality ratings as well as value-based hospital reimbursement. Notably, this study revealed that from 2015 to 2017 the MI decreased from 0.71 to 0.53, a 25.4% improvement, and the CMI of the vascular surgery inpatient cohort increased by 5.6%.

The authors note that the prevalence of 14 major comorbidities remained statistically stable throughout the study period, as did length of stay. This suggests that the patient population didn’t change over the study period.

Making the most of APP contributions

According to Dr. Lyden, the results of this analysis support the invaluable service APPs provide to vascular surgeons. “There is no question APPs help us meet the needs of an increasingly complex and aging patient population,” he says. “With the impending shortage of vascular surgeons, our dependence on them will surely grow. In addition to caring for our own patients with arterial and venous diseases, vascular surgery teams are invaluable to their overall hospitals as we support nearly every inpatient hospital service from cardiology and cardiac surgery to urology, orthopaedics, neurosurgery, ENT, interventional radiology and interventional neurology. Vascular surgeons take care of very complex, very sick patients, and we need help from APPs to do it. By providing direct patient care with accurate clinical documentation, APPs practicing at the top of their medical license can gain support through billing generated from their E/M and subsequent hospital care services.”

Related Articles

illustration of femoropopliteal bypass with the DETOUR system
January 10, 2024
Pooled 2-Year Outcomes of DETOUR Trials Support Percutaneous Transfemoral Arterial Bypass

Larger data set confirms safety, efficacy and durability for SFA lesions over 20 cm

image of human brain with an intracranial aneurysm
September 15, 2023
Intracranial Aneurysm Risk in Marfan Syndrome: Study Reveals Higher-Than-Expected Prevalence

Cleveland Clinic findings prompt efforts for broad data pooling

21-HVI-4131174-CQD-Paclitaxel-coated-devices-for-PAD
September 7, 2023
Paclitaxel-Coated Devices: How the Process of Ruling Out Safety Concerns Is Improving Vascular Surgery Research

Benefits of new FDA safety determination go beyond expanding patients’ options

imaging study of type II endoleak
August 16, 2023
Novel Approach to Transcaval Type II Endoleak Embolization Shows Safety and Efficacy

Technique features heavyweight guidewire and electrocautery to access the aortic sac

images of carotid bifurcation before and after TCAR
July 6, 2023
As CMS Mulls Broader Coverage of Carotid Stenting, Transcarotid Artery Revascularization Is Poised to Grow

A look at where TCAR and transfemoral carotid stenting are likely headed

22-HVI-3109643 carotid stent CQD 650×450
August 22, 2022
Advances Have Put Carotid Artery Stenting on Par With Surgery for Stroke Prevention

JACC review calls for CMS to update coverage decision

22-HVI-2977158_aberrant-right-subclavian-artery_650x450
June 8, 2022
Aberrant Right Subclavian Artery: When Best to Intervene?

Cleveland Clinic experience points to a symptoms- and complications-based approach

22-HVI-2928208 CQD 650×450
May 27, 2022
Gore Iliac Branch Endoprosthesis: Adding an Off-Label Stent Yields Outcomes Comparable to Those With Internal Iliac Component

Viabahn VBX offers a safe alternative option for endovascular aneurysm repair

Ad