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Improving Point-of-Care Ultrasound Documentation and Billing Accuracy in a Pediatric Emergency Department.


ABSTRACT: Objective:The performance and interpretation of point-of-care ultrasound (POCUS) should be documented appropriately in the electronic medical record (EMR) with correct billing codes assigned. We aimed to improve complete POCUS documentation from 62% to 80% and improve correct POCUS billing codes to 95% or higher through the implementation of a quality improvement initiative. Methods:We collected POCUS documentation and billing data from the EMR. Interventions included: (1) staff education and feedback, (2) standardization of documentation and billing, and (3) changes to the EMR to support standardization. We used P charts to analyze our outcome measures between January 2017 and June 2018. Results:Six hundred medical records of billed POCUS examinations were included. Complete POCUS documentation rate rose from 62% to 91%, and correct CPT code selection for billing increased from 92% to 95% after our interventions. Conclusions:The creation of a standardized documentation template incorporated into the EMR improved complete documentation compliance.

SUBMITTER: Ng C 

PROVIDER: S-EPMC7375490 | biostudies-literature | 2020 Jul-Aug

REPOSITORIES: biostudies-literature

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Improving Point-of-Care Ultrasound Documentation and Billing Accuracy in a Pediatric Emergency Department.

Ng Carrie C   Payne Asha S AS   Patel Amit K AK   Thomas-Mohtat Rosemary R   Maxwell Angela A   Abo Alyssa A  

Pediatric quality & safety 20200721 4


<h4>Objective</h4>The performance and interpretation of point-of-care ultrasound (POCUS) should be documented appropriately in the electronic medical record (EMR) with correct billing codes assigned. We aimed to improve complete POCUS documentation from 62% to 80% and improve correct POCUS billing codes to 95% or higher through the implementation of a quality improvement initiative.<h4>Methods</h4>We collected POCUS documentation and billing data from the EMR. Interventions included: (1) staff e  ...[more]

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