SHM Converge Scientific Abstract ePoster Gallery-Conquering the Complexity of Billing Guidelines With Physician Developed Template

Pdf Summary

This poster describes how the University of North Carolina Division of Hospital Medicine responded to the AMA’s January 2023 updates to CPT E/M billing codes and guidelines. The team found that education alone was not enough to change physician documentation and billing behavior, so they created a redesigned H&P note template to make compliance easier and improve revenue capture.<br /><br />A multidisciplinary group was convened in March 2023 to design the template. The goal was to make it efficient, align with the new guidelines, and preserve the H&P’s role as a communication tool. The updated template included four optional drop-down modifier statements: severity of illness, complexity of management for common scenarios, data review, and time-based billing with prolonged service inclusion.<br /><br />After group members tested and adapted the template in May 2023, all hospitalists were asked to use it in June 2023, replacing prior templates. The results showed a rapid increase in work RVUs (wRVUs) per encounter compared with education alone. There was also continued growth in July 2023, linked to greater use of prolonged care billing.<br /><br />The authors conclude that education by itself is insufficient for implementing complex clinical and billing changes. A physician-centered template, developed with end-user input, can effectively improve documentation efficiency and increase provider-based revenue while remaining practical for daily use.

Asset Subtitle

Clare Mock

Meta Tag

Author List Andrew Donohoe, Clare Mock, Danicella Younce, Leo Marucci, Paul Ossman, Rachel Knight

Category Innovations

Concept CPT EM Billing Guidelines

Concept Physician-Centric Note Template

Concept History and Physical Note

Concept Work RVU

Concept Physician Billing Performance

Distinguished Non-Finalist

Presenter Organization University of North Carolina School of Medicine

Presenting Author Clare Mock

Track Technology in Hospital Medicine

Keywords

CPT E/M billing

hospital medicine

UNC

documentation template

physician education

wRVUs

revenue capture

prolonged service billing

clinical documentation

billing guidelines

CPT EM Billing Guidelines

Physician-Centric Note Template

History and Physical Note

Work RVU

Physician Billing Performance