Implementation of Advanced Care Planning Standardized Documentation and Billing in the Emergency Department: A Retrospective Cohort Study.

Overview

abstract

BACKGROUND: Advanced care planning (ACP) conversations occur frequently in the emergency department (ED). However, such ACP discussions are inconsistently documented and rarely billed. OBJECTIVES: To implement a quality-improvement project aimed at increasing the frequency of ACP discussions held in the ED and standardizing the related documentation and billing. METHODS: The initiative was implemented at an urban academic center affiliated with a cancer center and included a templated note in the electronic health record that recorded ACP documents, surrogate decision-makers, and code status. ACP conversations are billable if discussions lasted > 16 min or if they were included in concurrent critical care time. Retrospective chart review was implemented after 1 year to obtain demographic, diagnostic, clinical, and billing data. In addition to descriptive statistics, we assessed for factors associated with billable (vs. unbillable) ACP time, presence of a designated surrogate decision-maker at the time of presentation, and receipt of palliative care services within 30 days. RESULTS: Over 12 months, a total of 448 patients had ACP discussions documented using the standardized note. Patients who participated in conversations averaged 72 years of age, and 53% were female. There were preexisting ACP documents in 31.4% of patients, but less than half had previously been uploaded into the medical record. Thirty-day mortality was 29.7%, and repeat visits or readmissions within 30 days occurred in 34.4% of patients discharged after the initial visit. Of encounters with ACP note documented, 6.5% had billable ACP time, 9.6% were eligible for ACP and critical care time, and 38.0% billed for critical care time. CONCLUSION: Templated notes can increase consistency of ACP documentation and create a billing opportunity in the ED.