Changes in Trauma Service Professional Fee Coding Following Electronic Health Record Implementation

Abstract

This retrospective study's purpose was to elucidate the effect of switching to an EHR on coding practices for the inpatient trauma and emergency surgery service at the University of California, Davis, Medical Center (UCDMC), an academic level I Trauma Center. Our hypothesis was that the implementation of an EHR would result in more complete notes and higher levels of coding, which in turn would increase professional fee revenue. Materials and Methods This study was approved by the Institutional Review Board of The University of California, Davis. De-identified data was extracted from the University Health System Consortium and Association of American Medical Colleges Faculty Practice Solution Center Database (FPSC). The FPSC is an analysis and benchmarking tool created from the direct download of coding data from over 80 participating academic medical centers. Both evaluation and management (E & M) and procedural coding are collected. Data can be sorted to focus on specific surgeons and services. Our analysis concentrated on surgeon members of the trauma and emergency surgery service who care for all trauma patients and 75% of the emergency surgery patients at the institution. The service manages its own critical care patients. UCDMC transitioned from handwritten notes to the EHR in May 2009. The transition was done all at once in a "big bang" approach wherein all of the note creation was switched from paper to electronic in a single day. The FPSC database was queried for notes written in calendar years 2008 and 2011 for a comparison of the year before and the year after implementation of the EHR.