Bridging the Gap: Optimizing Critical Care Billing in Pediatric Hospital Medicine

Accurate billing and coding are essential to the financial sustainability of children’s hospitals, particularly for pediatric hospital medicine (PHM) clinicians who may treat critically ill children outside of the intensive care unit (ICU).1–5 Despite delivering high-acuity care, especially during rapid response team (RRT) events for patients experiencing sudden clinical deterioration, pediatric hospitalists underuse critical care billing codes.3,4,6 This can lead to an underrepresentation of the complexity and acuity of care provided, with the potential for lost revenue.2–9As pediatric health care systems throughout the country face increasing financial pressure with more children’s hospitals becoming acquired, merging, or closing, accurately capturing justified reimbursement through appropriate billing is essential.4–9 However, efforts to improve billing are not just about revenue; they help to preserve access to high-quality pediatric care.7–9 Applying evaluation and management codes accurately in professional billing allows institutions to better measure clinician workload, support institutional operating margins, and guide resource allocation.3–5,8 These priorities can be further facilitated through the use of critical care billing codes. The American Medical Association (AMA) and Centers for Medicare & Medicaid Services (CMS) define critical care as the direct delivery of care to a patient with acute vital organ system failure who is at risk of imminent or life-threatening deterioration.10,11 These services can be provided by any billing clinician regardless of location, making the application of critical care codes highly relevant in PHM settings and during RRT events.6,10A recent quality improvement (QI) initiative by Allard et al assessed the use of time-based critical care current procedural terminology codes (99291, 99292) during eligible weekday, daytime RRTs on PHM services at a quaternary children’s hospital.6,11 The goal was to increase appropriate critical care code use from a baseline of 10% to at least 50% by July 2024. The primary outcome measure was the proportion of critical care codes applied during eligible RRT events and the secondary outcome evaluated the work relative value units (wRVUs) per RRT patient day. The balancing measure evaluated inappropriate code use when critical care criteria were not met.6Results showed that critical care billing for eligible RRT events increased from 10% to 94%, with documentation support improving from 13% to 90%. This led to a nearly 300% increase in wRVUs, generating 6.29 wRVUs per patient day using critical care codes vs 2.12 with standard inpatient codes. This translated to an additional $137 per patient day or approximately $28 000 in annual revenue. Notably, no inappropriate codes were applied, demonstrating the intervention’s effectiveness without overbilling.6Although the study by Allard et al focused on the application of critical care codes during eligible daytime RRT events, this work could be expanded on to include all RRT events in which critical care services may be provided, particularly in settings in which PHM clinicians support evening/overnight or 24/7 in-house coverage.6 Additionally, many hospitalized children may also meet criteria for critical care outside of RRTs. This includes patients with status asthmaticus on continuous albuterol, acute respiratory failure requiring high-flow nasal cannula, sepsis or septic shock requiring antibiotics and fluid resuscitation, and status epilepticus as examples. Despite this, critical care codes are still frequently underused in these settings.3,4,12System-wide efforts to improve critical care billing should focus on clinician education, enhancing documentation support, and emphasizing interprofessional collaboration.4,8 Establishing clear, reproducible eligibility criteria with additional specificity beyond the AMA and CMS definitions can help clinicians identify when critical care codes may apply. Electronic health record–integrated templates with built-in documentation prompts can increase adherence and serve as educational tools for clinicians to better understand coding and documentation requirements.4,12 Interdisciplinary efforts to engage pediatric hospitalists, ICU physicians, billing/coding specialists, as well as revenue cycle analysts can help align understanding and minimize potential insurance denials, especially when patients move between services (ie, between PHM and the ICU).4 This is particularly relevant during RRT and transfer events, in which both PHM and ICU teams may be involved, as CMS requires that services be distinct and nonduplicative. Although any billing clinician may apply time-based critical care codes (with ≥30 minutes of direct care), age-based global critical care codes (for patients under 5 years old) can only be billed once per institution per calendar day.10 Establishing clear transfer processes and mutually agreed-on coding practices between PHM and ICU teams is therefore vital to reducing denials and improving outcomes for both groups.4The findings from this QI initiative emphasize the need for similar interventions across institutions to improve clinician billing practices. PHM divisions should regularly audit and review billing performance and implement targeted education for both faculty and trainees. Many residents and early-career physicians lack confidence in accurately billing and documenting high-acuity care.13–15 Pediatric hospitalists especially need structured training and support on how to recognize and document the services provided appropriately. This could include establishing a dedicated billing curriculum for faculty and trainees that highlights common clinical scenarios with supporting documentation. Electronic medical record–based tools for real-time charge capture that incorporate clinician feedback with reminder prompts could be another intervention that may improve outcomes.4,12–15 Investing in physician advisors focused on billing optimization within PHM divisions may also yield a strong return on investment.The study by Allard et al demonstrates that targeted interventions can lead to meaningful improvements in billing accuracy among PHM clinicians. Improved billing practices not only enhance revenue but also reflect the scope and complexity of care provided by pediatric hospitalists.3–6,8 Accurately capturing these services is essential to demonstrating clinician value in PHM supporting institutional operating margins and strengthening the financial sustainability of our pediatric health care systems.3,4,6