Economics, Education, and Policy: Technical Communication
A handheld point-of-care (POC) electronic billing system using a personal digital assistant (PDA) was implemented to replace a paper-based system for acute pain management service (APMS) billing. A Medline search did not reveal any APMS handheld coding and billing. PDA medical billing usage in other specialties remains low with 4% of pediatricians using PDAs for billing.1 Handheld billing improves charge capture2 and coding accuracy for long-term care.3
This study was reviewed by the IRB and qualified as an exempt study; no consent was required. APMS anesthesiologists at the University of Kentucky received MDeverywhere (MDeverywhere, Long Island, NY) software training on a PDA for approximately 1 wk before any data collection. None had prior experience with handheld electronic billing. PDAs were carried by the APMS anesthesiologists while performing services enabling POC billing. All billing data were then downloaded and synchronized between the PDA, the desktop computer, and the central billing center. The handheld billing process is detailed in Figure 1.
Before the PDA, APMS anesthesiologists used a preprinted daily paper charge form for each patient which was hand-delivered to the administrative staff for entry into the Signature (Siemens Corporation, Boca Raton, FL) billing system. Data entry included case identification number, service date, patient and service location, provider number, diagnoses, referring physicians, and acute pain billing codes with modifiers. Patient services were captured only if entered on these forms.
Data were examined for a 12-mo period before PDA billing implementation (pre-elec) and compared to the same length of time after its implementation (post-elec), including most frequent charges (Table 1) and charge data (Table 2). Financial billing terminology definitions can be found in Table 3.
For each time period, the following were calculated and analyzed with an unpaired t-test: charge lag, days in accounts receivable (Table 2), net collection rate and bill production time (Table 4). Total number of timely denials (Table 4) for each period was analyzed using a z-test. The percentage of bills posted for each time period within 1 mo and for longer time periods (31–59, 60–89, and >90 days) were analyzed with a Fisher's exact test (Table 5). To account for trends over time, average days from service to billing per month were regressed on time within each period (pre-elec and post-elec) and then the slopes of the regressions were compared between periods using a t-test. A P value of <0.05 was considered significant. The return on investment to the anesthesiology department (Table 6) and costs to the enterprise for purchase and implementation of the system (Table 7) were calculated.
After handheld electronic implementation, the charge lag decreased while days in accounts receivable trended downward (Table 2); timely denials decreased while net collection rate increased (Table 4). More charges were submitted within 1 mo of service (Table 5) and bill production time was minimal requiring less time post-elec (Table 4).
The slopes of the time trends for the average number of days from service to billing were significantly different between the periods (P = 0.0002) with a positive slope for the pre-elec period and a negative slope for the post-elec period. Hence with adoption of handheld billing, the average number of days from service to billing began to decrease significantly with each month rather than increase. The return on investment to the anesthesiology department was 1.18 times (Table 6).
Implementation of a POC electronic billing using PDAs for an APMS to replace a paper-based billing system had a positive impact financially, and handheld PDA billing improved physician workflow. This approach for billing and coding has likely wide applicability as 55% of physicians4 and 70% of trainees,5 including anesthesiology residents documenting training,6 use PDAs or similar devices. PDAs have been used to capture preoperative assessment data with anesthesiology information management systems integration.7 Future possibilities include using a PDA to link surgical procedure and other pertinent data with APMS billing.
A limitation with our process was a desktop computer terminal requiring cradles for synchronization. A wireless network could transfer data rapidly and conveniently avoiding a desktop computer synchronization thus streamlining the billing process. Current charge capture software programs can use wireless transmission while maintaining security along the wireless pathway. As newer technologies become available, including the secure wireless data transfer to a PDA, integration with other systems becomes a reality and handheld devices may become routine in medical care.
The 6-mo preliminary data were accepted for abstract presentation at the ASA Annual Meeting in San Francisco, October 2007.
Thanks to Emily Topmiller for her assistance in preparation of this manuscript and Dr. Richard Kryscio and Jaime Johnson for their assistance with data analysis.
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© 2009 International Anesthesia Research Society
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