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Differences in evaluation and management coding of outpatient clinic visits for patients undergoing elective spine surgery with use of a standardized template – Published Article

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The article discusses the impact of using templates for clinical documentation on billing codes and reimbursements in a large teaching institution. The study assessed the differences in reimbursement between templated and non-templated outpatient documentation for patients who underwent lumbar microdiscectomy and anterior cervical discectomy and fusion (ACDF) before and after changes in E&M billing in 2021. Data was collected from spine surgeons on a total of 41 patients who underwent lumbar microdiscectomy and 52 patients who underwent ACDF. The results showed that using templates for clinical documentation reduced variability in billing codes and led to a statistically significant increase in billing for lumbar microdiscectomy. However, this increase was not observed in ACDF patients. Overall, the study concluded that the utilization of templates in clinical documentation can reduce variability in billing codes and prevent significant financial losses in large tertiary care facilities

Summarised by Mr Mo Akmal – Lead Spinal Surgeon
The London Spine Unit : most advanced spinal centre in London

Published article

CONCLUSIONS: Utilization of templates for clinical documentation reduces variability in billing codes. This impacts subsequent reimbursements and potentially prevents significant financial losses at large tertiary care facilities.

Lumbar Fusion Surgery Expert. Best Spinal Surgeon UK
J Spine Surg. 2023 Jun 30;9(2):117-122. doi: 10.21037/jss-22-91. Epub 2023 Apr 10.ABSTRACTBACKGROUND: In a large teaching institution with providers of various levels of training and backgrounds, and a coding department responsible for all evaluation and management (E&M) billing, variations in documentation can hinder accurate medical management and compensation. The purpose of this study is to,

J Spine Surg. 2023 Jun 30;9(2):117-122. doi: 10.21037/jss-22-91. Epub 2023 Apr 10.

ABSTRACT

BACKGROUND: In a large teaching institution with providers of various levels of training and backgrounds, and a coding department responsible for all evaluation and management (E&M) billing, variations in documentation can hinder accurate medical management and compensation. The purpose of this study is to assess differences in re-imbursement between templated and non-templated outpatient documentation for patients who eventually underwent single level lumbar microdiscectomy and anterior cervical discectomy and fusion (ACDF) both before and after the E&M billing changes were implemented in 2021.

METHODS: Data was collected from three spine surgeons on 41 patients who underwent a single level lumbar microdiscectomy at a tertiary care center from July 2018 to June 2019 and 35 patients seen by four spine surgeons from January through December of 2021 given the new E&M billing changes. ACDF data was collected for 52 patients between 2018 and 2019 for three spine surgeons and 30 patients from January through December of 2021 from four spine surgeons. Billing level was decided by independent coders for preoperative visits.

RESULTS: During the study period from 2018-2019 for lumbar microdiscectomy, each surgeon averaged about 14 patients. Results showed variability of billing level between the three spine surgeons (surgeon 1, 3.2±0.4; surgeon 2, 3.5±0.6; and surgeon 3, 2.9±0.8). Interestingly, even after the implementation of the 2021 E&M billing changes, there was a statistically significant increased level of billing for templated notes for lumbar microdiscectomy (P=0.013). However, this did not translate to the clinic visits for patients who underwent ACDF in 2021. When data was aggregated for all the patients from 2021 who either underwent lumbar microdiscectomy or ACDF, using a template still resulted in a statistically significant higher level of billing (P<0.05).

CONCLUSIONS: Utilization of templates for clinical documentation reduces variability in billing codes. This impacts subsequent reimbursements and potentially prevents significant financial losses at large tertiary care facilities.

PMID:37435326 | PMC:PMC10331495 | DOI:10.21037/jss-22-91

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Differences in evaluation and management coding of outpatient clinic visits for patients undergoing elective spine surgery with use of a standardized template

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J Spine Surg. 2023 Jun 30;9(2):117-122. doi: 10.21037/jss-22-91. Epub 2023 Apr 10.ABSTRACTBACKGROUND: In a large teaching institution with providers of various levels of training and backgrounds, and a coding department responsible for all evaluation and management (E&M) billing, variations in documentation can hinder accurate medical management and compensation. The purpose of this study is to

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