Actual and potential effects of medical resident coverage on reimbursement for inpatient visits by attending physicians

Abstract

Context: The impact of residents on hospital finance has been studied; there are no data describing the economic effect of residents on attending physicians.

Objective: In a community teaching hospital, we compared allowable inpatient visit codes and payments (based on documentation in the daily progress notes) between a general medicine teaching unit and nonteaching general medicine units.

Design: Retrospective chart review, matched cohort study.

Setting: Six hundred fifty-bed community teaching hospital.

Patients: Patients were discharged July 1998 through February 1999 from Saint Barnabas Medical Center. We randomly selected 200 patients in quartets. Each quartet consisted of a pair of patients cared for by residents and a pair cared for only by an attending physician. In each pair, 1 of the patients was under the care of an attending physician who usually admitted to the teaching service, and 1 was under the care of a usually nonteaching attending. Within each quartet, patients were matched for diagnosis-related group, length of stay, and discharge date.

Main outcome measures: We assigned the highest daily visit code justifiable by resident and attending chart documentation, determining relative value units (RVUs) and reimbursements allowed by each patient's insurance company.

Results: Although more seriously ill, teaching-unit patients generated a mean 1.75 RVUs daily, compared with 1.84 among patients discharged from nonteaching units (P =.3). Median reimbursement, daily and per hospitalization, was similar on teaching and nonteaching units. Nonteaching attendings documented higher mean daily RVUs than teaching attendings (1.83 vs 1.76, P =.2). Median allowable reimbursements were $267 per case ($53 daily) among teaching attendings compared with $294 per case ($58 daily) among nonteaching attendings (Z = 1.54, P =.1). When only the resident note was considered, mean daily RVUs increased 39% and median allowable dollars per day 27% (Z = 4.21, P <.001).

Conclusions: Nonteaching attendings appear to document their visits more carefully from a billing perspective than do teaching attendings. Properly counter-documented, resident notes could substantially increase payments to attending physicians.

FIGURE 1

Examples of resident and attending documentation. In (a), the attending physician failed to follow teaching guidelines, resulting in an allowable code of 99231 despite extensive resident documentation. In (b), the correct use of teaching criteria resulted in an allowable 99223 code, although the attending physician's note was brief.