SIC-IR Billing and Documentation

NCT ID: NCT00529854

Last Updated: 2008-02-27

Basic Information

• Recruitment Status: COMPLETED
• Total Enrollment: 814 participants
• Study Classification: OBSERVATIONAL
• Study Start Date: 2007-10-31
• Study Completion Date: 2007-12-31

Brief Summary

Accurate documentation in the patient medical record is critical to ensure proper diagnosis coding and subsequent hospital reimbursement. Multiple studies have demonstrated that clinicians often omit diagnoses which may result in insurance company denials and significant delays in payment. In addition, omitting diagnoses decreases the severity of patient illness which is often used as a risk adjustment tool to compare institution and physician outcomes. Medical informatics has been used to help improve accurate diagnosis documentation as well as improve billing efficiency. We plan to utilize a medical informatics program called SIC-IR (Surgical Intensive Care - Infection Registry) to improve documentation and attending billing efficiency within the surgical and trauma intensive care unit (STICU). We propose a six month study: a three month observational evaluation of current billing procedures followed by a three month prospective evaluation using a newly created SIC-IR billing module. The outcome measures will include the number of ICD-9 and CPT codes at discharge per patient, severity of patient illness based on documentation, STICU charges, number of insurance company denials, DRG relative weights, as well as a qualitative assessment of attending physician use of the electronic billing module. The observational and prospective patient populations will be compared for total patient-days in the STICU, ventilator-days, antibiotic-days, infectious complications per patient, and injury severity score (trauma patients only) to ensure the populations are similar and only the documentation and billing changes can account for our measured outcomes. We hypothesize that the SIC-IR billing module will increase the number of patient ICD-9 and CPT codes at discharge, increase severity of STICU patient illness via accurate documentation, increase total STICU charges, decrease insurance company denials, and be an efficient and well accepted electronic medical application.

Detailed Description

1. An observational evaluation will be performed for all STICU patients over a three month time period.

1. Data collected will be the outcome measures listed above (Number of ICD-9 codes at discharge, number of CPT codes at discharge, ext)

2. In addition the total number of STICU patient-days, ventilator-days, central line-days, confirmed infectious complications, injury severity scores for trauma patients, and antibiotic-days will be collected over the three month period. This will serve as a way to ensure the observational and prospective populations are not different, and only the documentation and billing methods changed.

2. The SIC-IR billing module will be released on October 1st, 2007 after attending physician training on its use.

3. A prospective evaluation will be performed for all STICU patients over a three month time period

1. Data collected will be the outcome measures listed above (Number of ICD-9 codes at discharge, number of CPT codes at discharge, ext)

2. In addition the total number of STICU patient-days, ventilator-days, central line-days, confirmed infectious complications, injury severity scores for trauma patients, and antibiotic-days will be collected over the three month period. This will serve as a way to ensure the observational and prospective populations are not different, and only the documentation and billing methods changed.

4. After the 3 month prospective evaluation, the attending physicians will be given a survey to document their acceptance or rejection of the billing module.

5. The observational and prospective documentation and billing data will be compared.

Conditions

Medical Record Documenation; Surgical and Trauma Intensive Care Unit Billing

Keywords

Intensive care unit; medical documentation; medical billing

Study Design

• Study Time Perspective: PROSPECTIVE

Study Groups

1

Observational evaluation of current billing and documentation practices

No interventions assigned to this group

2

Use of SIC-IR Billing Module

SIC-IR Billing Module

Intervention Type: OTHER

Medical informatic application designed to help with billing and documentation within the surgical and trauma intensive care unit

Interventions

SIC-IR Billing Module

Medical informatic application designed to help with billing and documentation within the surgical and trauma intensive care unit

Intervention Type: OTHER

Eligibility Criteria

Inclusion Criteria

• consecutive patients admitted to the surgical and trauma intensive care unit a a single level one trauma center care for by the surgical intensivist

Exclusion Criteria

• none

• Minimum Eligible Age: 18 Years
• Eligible Sex: ALL
• Accepts Healthy Volunteers: No

Sponsors

MetroHealth Medical Center

OTHER

Sponsor Role: lead

Principal Investigators

Joseph F Golob, MD

Role: STUDY_DIRECTOR

MetroHealth Medical Center

Jeffrey A Claridge, MD

Role: PRINCIPAL_INVESTIGATOR

MetroHealth Medical Center

Adam MA Fadlalla, PhD

Role: STUDY_DIRECTOR

Cleveland State University

Locations

MetroHealth Medical Center

Cleveland, Ohio, United States

Countries

United States

Other Identifiers

IRB07-00922

Identifier Type: -

Identifier Source: org_study_id