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SIC-IR Billing and Documentation (SIC-IR)

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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

Tracking Information
First Submitted Date September 13, 2007
First Posted Date September 14, 2007
Last Update Posted Date February 27, 2008
Study Start Date October 2007
Actual Primary Completion Date December 2007   (Final data collection date for primary outcome measure)
Current Primary Outcome Measures
 (submitted: February 26, 2008)
  • Number of ICD-9 codes at discharge (per patient) [ Time Frame: 6 months ]
  • Number of STICU specific ICD-9 codes at discharge (per patient) [ Time Frame: 6 months ]
  • Number of CPT codes at discharge (per patient) [ Time Frame: 6 months ]
  • Number of STICU specific CPT codes at discharge (per patient) [ Time Frame: 6 months ]
  • Number of specific evaluation and management codes used (per patient) [ Time Frame: 6 months ]
  • Total STICU charges at discharge (per patient) [ Time Frame: 6 months ]
  • Number of denied insurance claims (per month) [ Time Frame: 6 months ]
  • Estimated patient survival based on documentation (illness severity) (per patient) [ Time Frame: 6 months ]
  • DGR relative weight at discharge (per patient) [ Time Frame: 6 months ]
  • Qualitative assessment of attending approval of the SIC-IR module [ Time Frame: 6 months ]
Original Primary Outcome Measures Not Provided
Change History
Current Secondary Outcome Measures Not Provided
Original Secondary Outcome Measures Not Provided
Current Other Pre-specified Outcome Measures Not Provided
Original Other Pre-specified Outcome Measures Not Provided
 
Descriptive Information
Brief Title SIC-IR Billing and Documentation
Official Title Surgical and Trauma Intensive Care Unit Documentation and Billing Improvements With Medical Informatics
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.
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.
Study Type Observational
Study Design Time Perspective: Prospective
Target Follow-Up Duration Not Provided
Biospecimen Not Provided
Sampling Method Not Provided
Study Population All surgical and trauma intensive care unit patients addmitted to our reional Level I trauma center
Condition
  • Medical Record Documenation
  • Surgical and Trauma Intensive Care Unit Billing
Intervention Other: SIC-IR Billing Module
Medical informatic application designed to help with billing and documentation within the surgical and trauma intensive care unit
Study Groups/Cohorts
  • 1
    Observational evaluation of current billing and documentation practices
  • 2
    Use of SIC-IR Billing Module
    Intervention: Other: SIC-IR Billing Module
Publications * Not Provided

*   Includes publications given by the data provider as well as publications identified by ClinicalTrials.gov Identifier (NCT Number) in Medline.
 
Recruitment Information
Recruitment Status Completed
Actual Enrollment
 (submitted: February 26, 2008)
814
Original Estimated Enrollment
 (submitted: September 13, 2007)
600
Actual Study Completion Date December 2007
Actual Primary Completion Date December 2007   (Final data collection date for primary outcome measure)
Eligibility 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
Sex/Gender
Sexes Eligible for Study: All
Ages 18 Years and older   (Adult, Older Adult)
Accepts Healthy Volunteers No
Contacts Contact information is only displayed when the study is recruiting subjects
Listed Location Countries United States
Removed Location Countries  
 
Administrative Information
NCT Number NCT00529854
Other Study ID Numbers IRB07-00922
Has Data Monitoring Committee No
U.S. FDA-regulated Product Not Provided
IPD Sharing Statement Not Provided
Responsible Party Not Provided
Study Sponsor MetroHealth Medical Center
Collaborators Not Provided
Investigators
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
PRS Account MetroHealth Medical Center
Verification Date February 2008