PEDIATRICS Vol. 108 No. 4 October 2001, pp. 827-834

What If Pediatric Residents Could Bill for Their Outpatient Services?

Received Oct 18, 2000; accepted Feb 12, 2001.

Manny Ng^* and Stephen T. Lawless^{, §}

From the Departments of ^* Pediatrics and  Anesthesia/Critical Care, Thomas Jefferson University, Philadelphia, Pennsylvania; and ^§ Nemours Office of Operational Assessment, Nemours Foundation, and the Alfred I. duPont Hospital for Children, Wilmington, Delaware.

Objective.  We prospectively studied the potential of billing and coding practices of pediatric residents in outpatient clinics and extrapolated our results to assess the financial implications of billing inaccuracies. Using Medicare as a common measure of "currency," we also used the relative value unit (RVU) and ambulatory payment class methodologies as means of assessing the productivity and financial value of resident-staffed pediatric clinics.

Methods.  Residents were asked to submit voluntarily shadow billing forms and documentation of outpatient clinic visits. Documentation of work was assessed by a blinded reviewer, and current procedure terminology evaluation and management codes were assigned. Comparisons between resident codes and calculated codes were made. Financial implications of physician productivity were calculated in terms of dollar amounts and RVUs. Resource intensity was measured using the ambulatory payment class methodology.

Results.  A total of 344 charts were reviewed. Coding agreement for health maintenance visits was 86%, whereas agreement for acute care visits was 38%. Eighty-three percent of coding disagreement in the latter group was resulting from undercoding by residents. Errors accounted for a 4.79% difference in potential reimbursement for all visit types and a 19.10% difference for acute care visits. No significant differences in shadow billing discrepancies were found between different levels of training. Residents were predicted to generate $67 230, $87 593, and $96 072 in Medicare revenue in the outpatient clinic setting during each successive year of training. On average, residents generated 1.17 ± 0.01 and 0.81 ± 0.02 work RVUs for each health maintenance visit and office visit, respectively. Annual productivity from outpatient clinic settings was estimated at 548, 735, and 893 work RVUs in the postgraduate levels 1, 2, and 3, respectively.

Conclusion.  When pediatric residents are not trained adequately in proper coding practices, the potential for billing discrepancies is high and potential reimbursement differences may be substantial. Discussion of financial issues should be considered in curriculum development.  Key words:  ambulatory payment classes, graduate medical education, pediatric residency, physician billing and coding, prospective payment system, relative value units.

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