Templates and Training for Advanced Practitioners in Surgical Intensive Care Units

Providing templates for documenting patient care and instructing advanced practitioners (APs), such as advanced practice registered nurses and physician assistants, on proper use of the forms can help hospitals capture more revenue for services delivered in surgical intensive care units (ICUs). One year after Hartford Hospital in Connecticut introduced a program to optimize billing and documentation in its cardiothoracic (CTICU), neurosurgical (NICU), and general surgical (GSICU) ICUs, charge capture for the 3 units combined rose 48%. In a review of the program [Arch Surg. 2011;146(5):552-555], Karyn L. Butler, MD, and colleagues pointed out that as more people require critical care and as hospitals rely increasingly on APs to deliver care, facilities must find ways to capture charges associated with ICU visits more effectively. APs supply 24-hour coverage in the CTICU and NICU at Hartford Hospital; the GSICU relies on a blend of residents, fellows, and APs. In 2009, the hospital introduced a program requiring critical care APs to complete a daily progress note and a critical care event note at the conclusion of each 12-hour shift. The progress note documents systems reviews, system-based plans of care, and aggregate time spent delivering patient care. The event note records time spent providing critical care per acute event. Charges are entered into an electronic billing system. As part of the program, the APs attended educational sessions on coding evaluation and management (E&M) services, documenting services per Centers for Medicare & Medicaid Services regulations, and billing procedures. On the floor, attending physicians supply any necessary feedback to the APs on documentation practices. To assess the program’s effectiveness, the authors compared net revenue for critical care bills submitted by the APs under Current Procedural Terminology (CPT) codes 99291 and 99292 for the first quarter of fiscal years (FYs) 2008, 2009, and 2010. They also analyzed net revenue per unit per bed for these FYs. Compared with the first quarter of FY2008, net revenue declined in the first quarter of FY2009, when the program was undergoing implementation. A comparison between the first quarter of FY2008 and the first quarter of FY2010, however, revealed a substantial increase in each ICU’s net revenue for the specified CPT codes. In FY2010, the first year the program was fully operational, charge capture grew 70% in the CTICU, 39% in the NICU, and 25% in the GSICU; combined charges increased 48%. An assessment of net revenue captured per FY reflected a 40% combined increase for the ICUs from FY2008 to FY2010, with the greatest gain observed for the NICU. Breaking down revenue by bed continued to show increased revenue for all 3 units from FY2008 to FY2010. Although the GSICU had less AP coverage, it experienced the greatest increase (54%) in per-bed revenue between FY2008 and FY2010. An overall 18% increase in ICU AP salary offset was also observed. Many hospitals have turned to APs in response to restrictions from the Accreditation Council for Graduate Medical Education on how many hours residents can work. An advantage to using APs is that they can submit E&M charges for “aggregate time dedicated to the care of the critically ill patient,” said the authors, noting that postgraduate physicians cannot do this. The researchers also hypothesized that because APs do not rotate monthly, hospitals would benefit from using APs over nonresident providers in the ICU, since the APs would only require training on E&M guidelines and documentation once, thereby mitigating the negative effect of training on charge capture experienced in the study’s implementation phase.