Pitfalls of Extensive Documentation in the Emergency Department

QUALITY IMPROVEMENT

Ochsner Journal 20:299–302, 2020

DOI: 10.31486/toj.19.0108

Pitfalls of Extensive Documentation in the Emergency

Department

Andrea Blome, MD, MBA,

* Daohai Yu, PhD,

Xiaoning Lu, MS,

Kraftin E. Schreyer, MD

Department of Emergency Medicine, Temple University Hospital, Philadelphia, PA

Department of Clinical Sciences, Lewis Katz School of

Medicine at Temple University, Philadelphia, PA

Background: The law mandates careful record-keeping in the emergency department, and clinical imperatives also support the

value of complete and legible reports. A common assumption is that extensive documentation increases the yield of relative value

units (RVUs) and higher levels of care, thereby maximizing reimbursement. However, overdocumentation presents certain risks,

possibly impacts physician eciency, and does not ensure that records are more readable and clinically useful. We examined the

eect of increased documentation on actual reimbursement.

Methods: We conducted a 12-month productivity analysis of patients per hour (pt/h), RVUs per hour (RVU/h), amounts of monies

billed, and amounts of monies collected for all full-time supervising physicians in a university emergency medicine training pro-

gram.

Results: RVU/h vs pt/h yielded a positive linear relationship (R

=0.7571) and a strong correlation coecient of 0.87. RVU/h vs rev-

enue collection (amount actually paid) yielded a moderately positive linear relationship (R

=0.1752), with a correlation coecient

of 0.42. The relationship between pt/h and collections was weak (R

=0.0815), with a correlation coecient of 0.29. A quartile com-

parison showed an inection point, suggesting that after the third quartile, RVU/h did not appear to help generate signicantly

higher collections.

Conclusion: The data, while not denitive, suggest that overly extensive documentation may increase RVU totals but, after a point,

does not reliably increase revenue generation.

Keywords: Clinical coding, documentation, topography–medical

Address correspondence to Andrea Blome, MD, MBA, Department of Emergency Medicine, Ochsner Clinic Foundation, 1514 Jefferson Hwy.,

New Orleans, LA 70121. Tel: (504) 842-1533. Email: andrea.blome@ochsner.org

INTRODUCTION

Every emergency patient encounter requires documenta-

tion, and charting is expected to be thorough and accurate.

Aside from being a legal document, the emergency depart-

ment (ED) medical record has clinical and nancial functions.

Clinically, the medical record communicates vital information

to providers—whether the inpatient team, an ofce-based

physician, or the emergency medicine physician at succes-

sive visits. Medical records also form the basis of billing.

Compensation is based on the work performed as deter-

mined by coding. Generally done by a third party, coding

is the process of deconstructing the ED visit into a level of

service and the procedures performed.

Relative value units (RVUs) represent an arbitrary mea-

surement of physician work; they are measures of value

based on the Medicare reimbursement formulae for physi-

*Dr Blome is now afliated with the Department of

Emergency Medicine, Ochsner Clinic Foundation, New

Orleans, LA.

cian services.

RVUs extracted from medical records factor

into the compensation that the physician contributes to the

department. In the unique clinical setting of the ED, in which

patients present unpredictably with varying degrees of acu-

ity and complexity, RVUs track a confusing mix of cognitive

and procedural efforts. Unlike their colleagues in the surgi-

cal and medical departments, ED physicians generally have

no knowledge of how many RVUs will be generated for work

with a particular patient. Not surprisingly, billing efforts on

behalf of emergency physicians require trained billing spe-

cialists, either outsourced or in-house.

Different evaluation and management codes apply to the

context of a patient encounter, such as in-hospital or out-

patient visits, and factor into the level of service. The level

of service ranges from 1 to 5, with an additional designa-

tion for critical care, and is determined by how much clini-

cal information is documented in the history, review of sys-

tems, physical examination, and medical decision-making.

In general, the more complex the visit, the higher the level of

service.

Whether the physician is a direct employee, a con-

tractor, or a member of an independent group, documenting

Volume 20, Number 3, Fall 2020 299

Pitfalls of Extensive Documentation

and billing for all work legitimately performed is imperative.

Trainees are generally directed to document extensively.

Supervising physicians may also be encouraged by admin-

istrators or billing services to provide appropriate docu-

mentation to qualify for the highest appropriate level of

service.

The widespread use of electronic medical records allows

for fast and easy documentation with prepopulated tem-

plates and phrases. Templated medical records are designed

to efciently capture required histories (present illness, past

illnesses, social and family history, review of systems), objec-

tive ndings, and data review to justify coding levels. Emer-

gency medicine practice entails multitasking of clinical prob-

lems involving varying degrees of acuity and complexity.

The relative ease of computerized charting can allow for

careful review of systems pertinent to the chief complaint,

and an unsuspected issue may shed light on the present-

ing complaint. For instance, a patient presenting with leg

edema who is found to have pruritis on review of systems

would suggest a liver pathology as the cause. Further, an

incidental nding could lead to the discovery of an unre-

lated but signicant pathology. For example, a patient pre-

senting with ankle pain who is found to have unintentional

weight loss on review of systems may suggest an undiag-

nosed malignancy. Thorough use of a review of systems

may provide the physician with diagnostic acumen; however,

an extensive review of systems may also lead to notation

of system complaints that are not thoroughly investigated.

Casual reference to incidental ndings can be medicole-

gally problematic if the ndings are not fully investigated or

followed up.

What might be considered overdocumentation can also

result in overbilling. Third-party payers—such as gov-

ernment agencies, insurance companies, health mainte-

nance organizations, and employers—review emergency

medicine group practices. A group with high levels of

complex care billings could invite audits, resulting in pay-

backs and penalties. In rare cases, charges of fraud have

been leveled. For instance, Prime Healthcare Services, Inc.

agreed to pay $1.25 million to settle upcoding allegations

regarding falsied information about patient comorbidities

and complications.

As medical billing companies process

healthcare encounters into claims for insurance companies

and patients, they can provide protection against potential

penalties. To protect physicians and themselves, billing spe-

cialists may intentionally bill a medical record documented at

a level 5 to a lower level. In other words, careful charting by a

physician to justify a high level of service may be reimbursed

at a lower level.

Another consideration related to overdocumentation is

that time spent charting may be at the expense of patient

care. An observational study of ofce-based physicians

showed that physicians spent 2 hours on the computer for

every hour of patient time.

Although some charting is often

done after the scheduled end of shift, this study demon-

strated that charting takes more clinical time than direct

patient care.

Conceptually, given a cohort of ED patient encounters,

opportunities for reimbursement may be missed when chart-

ing is done in the context of a busy ED. Again, conceptually,

given the same cohort of emergency patients, there must be

a level at which all possible billable issues have been cap-

tured, and further documentation, from the point of view of

billing, would be overdocumentation.

While it is arguable to what degree extensively detailed

charting may be clinically valuable, a common assumption is

that adding more information to documentation will improve

reimbursement. To what degree this assumption is accurate

is the focus of this study.

METHODS

We conducted a 1-year productivity analysis of all super-

vising physicians (n=39) across 3 hospitals in an urban,

university emergency medicine training program located in

Philadelphia, PA. The health system serves an area of the

state in which 30% of the population lives below the federal

poverty level, and the majority of the payers are government-

funded programs such as Medicare and Medicaid.

All supervising physicians work 8-hour shifts, with a range

of 8 to 18 shifts per month. Physicians in training work during

most shifts at all 3 sites. The department at the main univer-

sity hospital is divided into 3 zones according to acuity. The

other hospitals in the system each have 1 designated main

ED and 1 minor care area. Minor care areas at all 3 sites

are staffed by advanced practice providers. No advanced

practice provider medical records were included in this

analysis.

At the study institution, a third-party company that con-

tracts with the health system handles billing. The electronic

medical record generates coding levels that the hospital’s

coding department conrms. The medical records are then

sent to the billing company for nal review.

Data for each supervising physician were assessed for

patients per hour (pt/h), RVUs per hour (RVU/h), amounts

of monies billed, and actual reimbursement from billings.

Ranges were averaged rst by physician. Because physi-

cians worked varying numbers of hours, we calculated per-

centages of reimbursement to billings to standardize the

evaluation. The relationships between RVU/h vs pt/h, RVU/h

vs revenue collected, and pt/h vs revenue collected were

determined. The R

value for each relationship was used

to determine variance, and a correlation coefcient was

also calculated. For trending purposes, physicians were

ranked and subsequently divided into RVU quartiles based

on billings and revenue collection percentages.

RESULTS

Among the 39 physicians, pt/h ranged from a low of 1.3

toahighof3.97.RVU/hrangedfromalowof3.97toahigh

of 10.07. A scatter plot of pt/h vs RVU/h showed a strong,

positive liner relationship (R

=0.7571) and a correlation coef-

cient of 0.87 (Figure 1).

Percentages of actual revenue collected vs billings ranged

from a low of 12.9% to a high of 23.1%. RVU/h vs revenue

collection yielded a moderately positive linear relationship

=0.1752) with a correlation coefcient of 0.42, suggesting

that adding more detail to documentation to produce higher

RVUs may not translate to increased revenue (Figure 2).

The analysis of pt/h vs revenue collection yielded a weak

relationship (R

=0.0815), with a correlation coefcient of

0.29 (Figure 3).

A quartile analysis and interaction plot comparing RVU/h

to percent revenue collections showed an increase in RVU/h

until the third quartile (Figures 4 and 5).

300 Ochsner Journal

Blome, A

Figure 1. Scatter plot demonstrating a strong linear rela-

tionship between patients seen per hour (pt/h) vs relative

value units per hour (RVU/h) for each supervising physician.

A trend line is included, with an R

of 0.7571.

Figure 2. Scatter plot of relative value units per hour (RVU/h)

plotted against percent revenue collection demonstrating a

moderate positive linear relationship, with an R

of 0.1752.

Figure 3. Scatter plot of patients seen per hour (pt/h) vs per-

cent revenue collection demonstrating a weak linear rela-

tionship, with an R

of 0.0815, implying a very limited pre-

dictability of pt/hr for the percentages of actual revenue col-

lection.

Figure 4. Quartile graph of relative value units per hour

(RVU/h) rank vs percent revenue collection demonstrating

an increase in revenue collection until the third quartile.

DISCUSSION

This study suggests an inection point at which docu-

mentation for more RVUs did not appear to generate signi-

cantly higher collections. Beyond this point, the ED physician

may be documenting too much. While complex patients may

need extensive documentation, for a range of patients, over-

documentation is not without hazard. Medicolegally, docu-

mentation of less clinically pertinent issues that are not fully

investigated may be hard to defend, as can documenta-

tion of negative system reviews that are not matched by in-

depth history taking. Clinically, more time spent document-

ing indicates less time spent with patients.

Documenta-

tion of history-taken positives not apparently relevant to the

immediate clinical problem could mandate special studies

and procedures that could extend length of stay and impair

patient ow.

Electronic medical records have made charting easier and

quicker to accomplish, as well as provided ready access

to complete and legible records. As with all technologies,

computerized charting is not without its downsides and may

sometimes lead to its own form of overuse.

One limitation of this retrospective observational study is

that metrics for RVU/h, pt/h, billings, and revenue collec-

tions are precise but only for an institution with a poor payer

Figure 5. Interaction plot of relative value units per hour

(RVU/h) rank vs percent revenue collection demonstrating

an inection point after which percent revenue collection no

longer increases.

Volume 20, Number 3, Fall 2020 301

Pitfalls of Extensive Documentation

mix. A similar study in a more afuent demographic might

show greater variability in reimbursement yields. In addition,

this study was conducted at a training university health sys-

tem with training physicians rotating in all 3 hospitals in the

system. The training physicians chart, but the supervising

physician is responsible for the nal documentation and can

edit a trainee’s charting. Time devoted to training physicians

likely impacted throughput and documentation. Further, sim-

ilar to the training physicians, the supervising physicians

rotate among the 3 hospital sites. Because of the way treat-

ment zones are apportioned, physicians have little opportu-

nity to preferentially choose lower acuity patients who would

require less treatment time. Advanced practice providers see

the patients requiring minor treatment during the day and

evening shifts but not overnight. The 5 nocturnists, there-

fore, see more lower acuity volume than the physicians work-

ing day and evening shifts. Seeing lower acuity patients

on the overnight shift could allow physicians to treat more

patients per hour which would impact the results of the anal-

ysis. For the remaining physicians, discrepancies in acuity

should equalize over the course of a year. Scribes, who were

employed in lower acuity zones and occasionally in minor

care areas, may have impacted efciency, but that was not

analyzed in this study. Finally, the data were compiled for

each physician for a 1-year time period, and more granular

data, such as by shift, were not obtained.

CONCLUSION

The importance of accurate and detailed medical doc-

umentation is inarguable. However, our data indicate an

inection point beyond which documentation did not appear

to generate signicantly higher collections. Documentation

should, therefore, focus on important clinical information

rather than on billing outcomes.

ACKNOWLEDGMENTS

This study was presented orally at the National Soci-

ety for Academic Emergency Medicine (SAEM) and won

the ﬁrst-place award for resident presentation at the SAEM

Mid-Atlantic Regional Conference Plenary Session in March

2017. The authors have no ﬁnancial or proprietary inter est in

the subject matter of this article.

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