During the study period, there were 4470 total visits with at least one bronchodilator treatment 182

1
Effectiveness of a Clinical/Billing Alert System
vs Education Alone in Assisting Physicians to
Correctly Bill for Asthma Nebulization Treatments
in the Pediatric Office Setting Lisa Biggs MD,
Robert W. Grundmeier MD, Anthony A. Luberti MD,
MSIS
The Childrens Hospital of Philadelphia
RESULTS (see also Table 2)
METHODS
BACKGROUND

• Using the electronic health record (EHR,
  EpicCare, by Epic Systems Corporation, Madison,
  WI), data from all office visits to 4 urban
  primary care centers (PCC) and 22 Kids First
  suburban pediatric practices (KF) of The
  Childrens Hospital of Philadelphia were
  retrieved for the interval 2/1/2006 to 2/28/2007
  for patients with a diagnosis of asthma (ICD9
  codes 493.xx)
• Prior to August 2006, training and education was
  provided on the proper use of CPT code 96460
  (Airway Inhalation Treatment) for the billing of
  office bronchodilator treatments within the EHR
  (Table 1).
• In August 2006 an automated intervention in the
  form of an alert (called Charge Advisor) was
  offered for all prescribing providers in all
  practices (except 4 primary care practices where
  the intervention began for resident physicians in
  October 2006). At the time of ordering one of
  the bronchodilator treatments, if CPT code 96460
  was not also entered an alert would trigger
  (Figure 1). Users have the option of billing or
  overriding the alert. An additional reminder
  alert was also offered at the time of closing
  the encounter if the provider had neglected to
  bill appropriately.
• Visits with patients with a diagnosis of asthma
  with office administration of a bronchodilator
  were reviewed to determine if inhalation therapy
  was billed at least once. Percentage rates that
  met this criteria were calculated for the time
  period 6 months prior to and post intervention
  for each practice. (Table 2) Data was evaluated
  using chi-squared tests for statistical
  significance.

• Office treatment of acute asthma via nebulized
  medication is one of the most common procedures
  performed in our ambulatory primary care network.
• Based on an independent audit of 10 charts per
  physician , CPT code 94640 (inhalation therapy
  for administration of nebulized medication) was
  the procedure most commonly documented, but not
  billed.
• There is evidence that clinical alerts,
  triggered at the point of service, reduce
  medication errors, improve immunization rates and
  improve adherence to evidence based guidelines
• To our knowledge there is no study that
  evaluates if billing alerts, similar to clinical
  decision support alerts assist clinicians with
  correct billing and coding.

• During the study period, there were 4470 total
  visits with at least one bronchodilator treatment
  (1829 visits pre-intervention and 2641 visits
  post-intervention)
• For these visits, alert activation showed
  immediate and significant increase in charge
  capture rates (67 pre vs 93 post-intervention,
  p lt 0.00001).
• Similar improvements were noted with PCC
  specific visits (n 2017, 54 pre vs 87
  post-intervention, p lt 0.00001) and KF specific
  visits (n 2453, 77 pre vs 98
  post-intervention, p lt 0.00001)
• Individually, all 26 total practices (KF and PCC)
  showed an increase in the percentage of visits
  with the proper use of CPT code 96460 after the
  intervention (with the exception of 2 practices
  where the pre-intervention billing rate was
  already 100)
• For those 10 KF practices which already had a
  pre-intervention billing rate gt 85, there was an
  increase in the percentage of billing, but these
  practices did not reach statistical significance.

Table 2 Comparison of billing results pre- and
post-intervention
Figure 1. Automated alert if CPT code 96460 not
included at the time of ordering a bronchodilator
agent listed in Table 1
OBJECTIVES

• Evaluate if a billing alert system, improves
  clinician generated charge capture rate of CPT
  code 96460, when ordering an office administered,
  nebulized medication.

CONCLUSIONS

• This billing alert led to a statistically
  significant improved charge capture rate of CPT
  code 96460.
• Practices that already successfully capture
  charges, although still showing improvement with
  the introduction of an alert, may not reap enough
  benefit to justify the technical work required to
  build the alerts.

Table 1. Bronchodilator agents
LIMITATIONS

• Because our methodology evaluated if at least
  one inhalation code was ordered when any
  nebulized medication was ordered (instead of
  assessing for a 11 correlation of specific
  orders) there may be inflation of the improvement
  rates. Although some charges may be missed there
  is still significant improvement.
• Because two types of alerts were used in this
  study, it is unclear if there is a difference in
  the type of alert offeredthe one at the point of
  care or the reminder alert at the close of
  encounter.

When ordering a bronchodilator (as above), if CPT
code 96460 is not also entered, an alert at the
time of signing advises the user of how to
proceed.
FUTURE DIRECTIONS

• Our findings suggest alerting methods within the
  EHR can potentially positively impact other
  aspects of billing.
• Additional refinement of this particular
  screening tool is needed to improve accuracy of
  results and measure any difference in results
  afforded by the type of alert.

• Contact Information
• Email luberti_at_email.chop.edu
• All Authors from Primary Care and AAL and RWG
  from The Center for Biomedical Informatics at
  CHOP
• We gratefully acknowledge Alex Fiks, MD for his
  assistance with statistical calculations.