- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT00529854
SIC-IR Billing and Documentation (SIC-IR)
February 26, 2008 updated by: MetroHealth Medical Center
Surgical and Trauma Intensive Care Unit Documentation and Billing Improvements With Medical Informatics
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.
Study Overview
Status
Completed
Intervention / Treatment
Detailed Description
An observational evaluation will be performed for all STICU patients over a three month time period.
- Data collected will be the outcome measures listed above (Number of ICD-9 codes at discharge, number of CPT codes at discharge, ext)
- 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.
- The SIC-IR billing module will be released on October 1st, 2007 after attending physician training on its use.
A prospective evaluation will be performed for all STICU patients over a three month time period
- Data collected will be the outcome measures listed above (Number of ICD-9 codes at discharge, number of CPT codes at discharge, ext)
- 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.
- After the 3 month prospective evaluation, the attending physicians will be given a survey to document their acceptance or rejection of the billing module.
- The observational and prospective documentation and billing data will be compared.
Study Type
Observational
Enrollment (Actual)
814
Contacts and Locations
This section provides the contact details for those conducting the study, and information on where this study is being conducted.
Study Locations
-
-
Ohio
-
Cleveland, Ohio, United States, 44109
- MetroHealth Medical Center
-
-
Participation Criteria
Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.
Eligibility Criteria
Ages Eligible for Study
18 years and older (Adult, Older Adult)
Accepts Healthy Volunteers
No
Genders Eligible for Study
All
Study Population
All surgical and trauma intensive care unit patients addmitted to our reional Level I trauma center
Description
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
Study Plan
This section provides details of the study plan, including how the study is designed and what the study is measuring.
How is the study designed?
Design Details
Cohorts and Interventions
Group / Cohort |
Intervention / Treatment |
---|---|
1
Observational evaluation of current billing and documentation practices
|
|
2
Use of SIC-IR Billing Module
|
Medical informatic application designed to help with billing and documentation within the surgical and trauma intensive care unit
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Time Frame |
---|---|
Number of ICD-9 codes at discharge (per patient)
Time Frame: 6 months
|
6 months
|
Number of STICU specific ICD-9 codes at discharge (per patient)
Time Frame: 6 months
|
6 months
|
Number of CPT codes at discharge (per patient)
Time Frame: 6 months
|
6 months
|
Number of STICU specific CPT codes at discharge (per patient)
Time Frame: 6 months
|
6 months
|
Number of specific evaluation and management codes used (per patient)
Time Frame: 6 months
|
6 months
|
Total STICU charges at discharge (per patient)
Time Frame: 6 months
|
6 months
|
Number of denied insurance claims (per month)
Time Frame: 6 months
|
6 months
|
Estimated patient survival based on documentation (illness severity) (per patient)
Time Frame: 6 months
|
6 months
|
DGR relative weight at discharge (per patient)
Time Frame: 6 months
|
6 months
|
Qualitative assessment of attending approval of the SIC-IR module
Time Frame: 6 months
|
6 months
|
Collaborators and Investigators
This is where you will find people and organizations involved with this study.
Sponsor
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
Study record dates
These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.
Study Major Dates
Study Start
October 1, 2007
Primary Completion (Actual)
December 1, 2007
Study Completion (Actual)
December 1, 2007
Study Registration Dates
First Submitted
September 13, 2007
First Submitted That Met QC Criteria
September 13, 2007
First Posted (Estimate)
September 14, 2007
Study Record Updates
Last Update Posted (Estimate)
February 27, 2008
Last Update Submitted That Met QC Criteria
February 26, 2008
Last Verified
February 1, 2008
More Information
Terms related to this study
Additional Relevant MeSH Terms
Other Study ID Numbers
- IRB07-00922
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
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