Development of Consultation Form for Facial Trauma Evaluation and Its Effect On CPT Coding and Billing

Purpose:

Evaluate the effect of a standardized Facial Trauma Consultation Form on CPT coding level and billing.

 

Introduction:

Facial trauma is among the most frequent consultations encountered by plastic surgeons and can become an integral part of any plastic surgery practice. Unfortunately, the reimbursement from these consultations can be low and qualified plastic surgeons may be tempted to exclude facial trauma from their practice.¹ 

At our institution, we found that the coding level and subsequent reimbursement is highly dependent on the information garnered during the consultation history and physical examination. An audit of our records found that our documentation practices were lacking and we were we not capturing the full CPT code.

Similarly, Barnes et al was faced with falling reimbursement rates at the University of Cincinati Trauma Center. He, however, found a remarkable increase in billing of 394% by instituting standardized daily progress note forms.²

Taking a cue from Barnes et al, we devised a Facial Trauma Consultation form to to ensure complete examination and to aid with documentation, coding, and billing.

Methods: 

The Plastic Surgery Division, in consultation with our billing and coding department, developed a concise Facial Trauma Consultation Form (figure 1). 

            Under the guidance of division faculty, two plastic surgery residents performed 10 consultations each without the aid of the consult form followed by 10 consultations each with the aid of the form. The CPT codes and billing data for these consultations were then obtained from the billing department for comparison.

Results: 

40 total consultations were documented – 20 consultations without the form and 20 consultations with the form. When the form was not used, the CPT code level was 2.95 and the average bill was $392 per consult. In contrast, when the form was used, the average CPT code level was 3.6 and the average bill was $524. This represents an increase in billing of 33.4% when the consultation form is used.

Conclusions: 

The use of the Facial Trauma Consultation Form has resulted in more complete documentation and a subsequent increase in CPT coding and billed services.

Figure 1

References:

1.) A financial analysis of operative facial fracture management. Plast Reconstr Surg. 2008 Apr;121(4):1323-7.

2.) The devil is in the details: maximizing revenue for daily trauma care. Surgery. 2008 Oct;144(4):670-5; discussion 675-6