Changes in Trauma Service Professional Fee Coding Following Electronic Health Record Implementation

Abstract

Background: Implementing an electronic health record (EHR) system is an expensive and large-scale project. Few studies have examined the impact of inpatient EHRs on documentation, coding levels, and professional fee reimbursement. Trauma and Emergency Surgery services are ideal for studying this question given their high percentage of inpatient evaluation and management (E & M) work. This study elucidates effects of an EHR on coding practices for the inpatient Trauma and Emergency Surgery Service at an academic level I Trauma Center. We hypothesize that EHR implementation leads to higher coding levels and increased professional fee revenue. Methods: De-identified data was extracted from the University Health System Consortium and Association of American Medical Colleges Faculty Practice Solution Center database. Our medical center transitioned from written physician notes to the EHR in May 2009. The database was queried for notes written by the Trauma and Emergency Surgery service in calendar years 2008 and 2011 to compare years before and after EHR implementation. The CPT codes of interest were for E & M Initial Hospital Care (99221, -2, and -3) and Subsequent Hospital Care (99231, -2, and -3). Coding levels were linked to standard Medicare Relative Value Units. Professional coders were used throughout and coding guidelines were unchanged over the study period. Results: Coding levels for Initial Hospital Care notes increased immediately and markedly. Revenue from these codes increased by 28.1% while Subsequent Hospital Care codes increased less dramatically by 1.7%. Conclusions: The increase in higher E & M coding levels due to HER implementation was financially significant, immediate, and durable. The increase in total Initial Hospital Care notes resulted from improved coder note recognition and higher note quality. Revenue increased measurably.