Working…
ClinicalTrials.gov
ClinicalTrials.gov Menu

SIC-IR Billing and Documentation (SIC-IR)

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details.
 
ClinicalTrials.gov Identifier: NCT00529854
Recruitment Status : Completed
First Posted : September 14, 2007
Last Update Posted : February 27, 2008
Sponsor:
Information provided by:
MetroHealth Medical Center

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.

Condition or disease Intervention/treatment
Medical Record Documenation Surgical and Trauma Intensive Care Unit Billing Other: SIC-IR Billing Module

Detailed Description:
  1. An observational evaluation will be performed for all STICU patients over a three month time period.

    1. Data collected will be the outcome measures listed above (Number of ICD-9 codes at discharge, number of CPT codes at discharge, ext)
    2. In addition the total number of STICU patient-days, ventilator-days, central line-days, confirmed infectious complications, injury severity scores for trauma patients, and antibiotic-days will be collected over the three month period. This will serve as a way to ensure the observational and prospective populations are not different, and only the documentation and billing methods changed.
  2. The SIC-IR billing module will be released on October 1st, 2007 after attending physician training on its use.
  3. A prospective evaluation will be performed for all STICU patients over a three month time period

    1. Data collected will be the outcome measures listed above (Number of ICD-9 codes at discharge, number of CPT codes at discharge, ext)
    2. In addition the total number of STICU patient-days, ventilator-days, central line-days, confirmed infectious complications, injury severity scores for trauma patients, and antibiotic-days will be collected over the three month period. This will serve as a way to ensure the observational and prospective populations are not different, and only the documentation and billing methods changed.
  4. After the 3 month prospective evaluation, the attending physicians will be given a survey to document their acceptance or rejection of the billing module.
  5. The observational and prospective documentation and billing data will be compared.

Layout table for study information
Study Type : Observational
Actual Enrollment : 814 participants
Time Perspective: Prospective
Official Title: Surgical and Trauma Intensive Care Unit Documentation and Billing Improvements With Medical Informatics
Study Start Date : October 2007
Actual Primary Completion Date : December 2007
Actual Study Completion Date : December 2007

Resource links provided by the National Library of Medicine


Group/Cohort Intervention/treatment
1
Observational evaluation of current billing and documentation practices
2
Use of SIC-IR Billing Module
Other: SIC-IR Billing Module
Medical informatic application designed to help with billing and documentation within the surgical and trauma intensive care unit




Primary Outcome Measures :
  1. Number of ICD-9 codes at discharge (per patient) [ Time Frame: 6 months ]
  2. Number of STICU specific ICD-9 codes at discharge (per patient) [ Time Frame: 6 months ]
  3. Number of CPT codes at discharge (per patient) [ Time Frame: 6 months ]
  4. Number of STICU specific CPT codes at discharge (per patient) [ Time Frame: 6 months ]
  5. Number of specific evaluation and management codes used (per patient) [ Time Frame: 6 months ]
  6. Total STICU charges at discharge (per patient) [ Time Frame: 6 months ]
  7. Number of denied insurance claims (per month) [ Time Frame: 6 months ]
  8. Estimated patient survival based on documentation (illness severity) (per patient) [ Time Frame: 6 months ]
  9. DGR relative weight at discharge (per patient) [ Time Frame: 6 months ]
  10. Qualitative assessment of attending approval of the SIC-IR module [ Time Frame: 6 months ]


Information from the National Library of Medicine

Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the contacts provided below. For general information, Learn About Clinical Studies.


Layout table for eligibility information
Ages Eligible for Study:   18 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Study Population
All surgical and trauma intensive care unit patients addmitted to our reional Level I trauma center
Criteria

Inclusion Criteria:

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

Exclusion Criteria:

  • none

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT00529854


Locations
Layout table for location information
United States, Ohio
MetroHealth Medical Center
Cleveland, Ohio, United States, 44109
Sponsors and Collaborators
MetroHealth Medical Center
Investigators
Layout table for investigator information
Study Director: Joseph F Golob, MD MetroHealth Medical Center
Principal Investigator: Jeffrey A Claridge, MD MetroHealth Medical Center
Study Director: Adam MA Fadlalla, PhD Cleveland State University
Layout table for additonal information
ClinicalTrials.gov Identifier: NCT00529854    
Other Study ID Numbers: IRB07-00922
First Posted: September 14, 2007    Key Record Dates
Last Update Posted: February 27, 2008
Last Verified: February 2008
Keywords provided by MetroHealth Medical Center:
Intensive care unit
medical documentation
medical billing
Additional relevant MeSH terms:
Layout table for MeSH terms
Wounds and Injuries