SIC-IR Billing and Documentation

NCT00529854 | Completed

• 1 other identifier: IRB07-00922
• Study Type: observational
• Target: 814
• Locations: 1 country
• Sites: 1

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.

Conditions

Medical Record Documenation; Surgical and Trauma Intensive Care Unit Billing

Keywords

Intensive care unit; medical documentation; medical billing

Outcome Measures

Primary Outcomes (10)

• Number of ICD-9 codes at discharge (per patient)

  6 months

• Number of STICU specific ICD-9 codes at discharge (per patient)

  6 months

• Number of CPT codes at discharge (per patient)

  6 months

• Number of STICU specific CPT codes at discharge (per patient)

  6 months

• Number of specific evaluation and management codes used (per patient)

  6 months

• Total STICU charges at discharge (per patient)

  6 months

• Number of denied insurance claims (per month)

  6 months

• Estimated patient survival based on documentation (illness severity) (per patient)

  6 months

• DGR relative weight at discharge (per patient)

  6 months

• Qualitative assessment of attending approval of the SIC-IR module

  6 months

Study Arms (2)

1

Observational evaluation of current billing and documentation practices

2

Use of SIC-IR Billing Module

Other: SIC-IR Billing Module

Interventions

SIC-IR Billing Module OTHER

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

2

Eligibility Criteria

• Age: 18 Years+
• Sex: all
• Healthy Volunteers: No
• Age Groups: Adult (18-64), Older Adult (65+)

Study Population

All surgical and trauma intensive care unit patients addmitted to our reional Level I trauma center

You may qualify if:

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

You may not qualify if:

• none

Sponsors & Collaborators

• MetroHealth Medical Center: lead

Study Sites (1)

MetroHealth Medical Center

Cleveland, Ohio, 44109, United States

Location

Study Officials

• Joseph F Golob, MD

  MetroHealth Medical Center

  STUDY DIRECTOR

• Jeffrey A Claridge, MD

  MetroHealth Medical Center

  PRINCIPAL INVESTIGATOR

• Adam MA Fadlalla, PhD

  Cleveland State University

  STUDY DIRECTOR

Study Design

• Study Type: observational
• Time Perspective: PROSPECTIVE
• Sponsor Type: OTHER

Study Record Dates

• First Submitted: September 13, 2007
• First Posted: September 14, 2007
• Study Start: October 1, 2007
• Primary Completion: December 1, 2007
• Study Completion: December 1, 2007
• Last Updated: February 27, 2008

Record last verified: 2008-02

Locations

US (1)