Roger's Textbook of Pediatric Intensive Care - Chapter 6

Chapter 6
Practice Management: The Business of Pediatric Critical Care
Alice D. Ackerman
J. Marc Harrison
The business of critical care has become increasingly complex. Managing that business requires intimate knowledge of the field, understanding of the environment, and the ability to converse with hospital and system administrators in a way that enables the physician or other healthcare provider to accomplish necessary actions on behalf of the patient. Attention to the business of practicing critical care is exceedingly important. Much like the discussion of leadership in Chapter 4, the rudiments of business planning and management must be understood by all practitioners hoping to develop an effective and efficient PICU. Although the term “practice management” for physicians in outpatient settings revolves around maximizing practice income and managing staff, in the hospital-based setting of the PICU, the areas of interest are similar, but in many ways distinct. This chapter addresses the financing of PICUs and critical care practices, as well as issues of billing and coding, physician compliance, recruitment and retention of critical care practitioners, performance evaluation, and productivity measurement. In addition, some aspects of new program development, including the basics of how to write a business plan, are discussed. The chapter is necessarily limited in scope and serves more as a reference to additional materials than as a definitive work in and of itself.
Financing the Unit and the Practice
Hospital Costs and Billing
Much attention has been paid in the American and European literature to the costs of critical care. The US spent $5267 per capita on healthcare services in 2002, over $3000 more than the median of the 30 countries that participate in the Organization for Economic Cooperation and Development; healthcare spending accounted for 14.6% of the US gross domestic product (8). Switzerland, the next in line, spent 11.2% of its gross domestic product, or the equivalent of $3446 per capita. Identifying the ways in which healthcare dollars are spent reveals that critical care accounts for ~20% of inpatient costs, or 0.9% of the gross domestic product (17) in the US. Although efforts at controlling costs in adult ICUs have been given significant attention in the medical, economic, and quality-care literature, little is known about the costs of pediatric critical care globally. The ICU is a cost-intensive environment, and it is therefore important for the practitioner to remain cost conscious while providing pediatric and neonatal critical care services. However, given the relatively small size of the PICU population compared to that of adult ICU users, the overall impact of reducing pediatric critical care costs will be much less important to a nation's overall healthcare expenditures. In the US, however, this fact has not prevented government officials from making cuts in aid programs such as Medicaid, which specifically, although unintentionally, harm children disproportionately to adults (3). We must therefore strive to be cost conscious and cost efficient while we provide the best care possible to our patients.
Internationally, PICUs are funded in many different ways. Whether they and their medical and nursing staffs are funded by the government, private organizations, or by a mechanism of private/public healthcare insurance, financial issues are important. Financing the hospital-based costs (equipment, space, nursing, ancillary personnel) is often different from financing the costs of the attending physicians. The costs of graduate medical education may also play a significant role in the various systems.
An exhaustive review of the financing, cost, and structure of pediatric critical care services worldwide is beyond the scope of this chapter. The authors have concentrated on the situation in the US, due to the paucity of comparable international data.
In the US, most hospital services are funded through a diagnosis-related group (DRG)-based system, although the specific nature of this scheme varies from state to state. Hospitals receive funding in a prospective manner as determined by the Centers for Medicare and Medicaid Services (CMS). The DRG system for calculating prospective payments to hospitals for inpatient services began in 1983 and has undergone only minor changes to date. In general, it establishes norms for lengths of stay for groups of diagnoses, and hospitals are paid for the average length of stay for a particular diagnosis, regardless of how long the patient actually remains in the hospital. Various comorbidities may increase the weight of the DRG for any particular patient, leading to higher-than-average reimbursement. The average weight of all DRGs for an individual hospital is known as the case-mix index. In addition, most payers, including CMS, have a mechanism to identify “outliers” and can reimburse differently for such patients.
New changes planned for FY 2007 and beyond will alter the way the federal government calculates the prospective payment based on these codes. The changes are being initiated due to perceived inequities in the current system. CMS alleges that certain poorly reimbursed but highly needed services are unavailable, whereas other potentially less-needed but better-reimbursed services are overly available. The changes will occur in two areas. One is predicted to change the case-mix index of medical, compared to surgical, patients. The other is

anticipated to shift payments between hospitals. It will change payments based on severity of illness (6). Therefore, hospitals with a higher proportion of critically ill patients are likely to receive additional reimbursement.
The effectiveness of such a program will depend on appropriate International Classification of Disease (ICD)-9 coding and complete physician documentation. A larger number of diagnostic groups will be recognized by the new system. It is likely to be more useful in pediatrics than is the current DRG system used by CMS. Additionally, CMS is undertaking an evaluation of potential alternatives to the current DRG severity system (6).
Some states' Medicaid programs use a DRG system with a pediatric modification to determine reimbursements to children's hospitals and large pediatric services within general hospitals (24). Although it is more closely reflective of actual pediatric length of stay data, it is not universally accepted by all states or payers.
Physician Billing and Compliance
With apologies to the international community, the information in this section refers exclusively to billing and compliance in the US. In the US, physician or other provider billing is separate from hospital billing. Physicians generate charges based on codes [current procedural terminology (CPT) codes] that describe work done and justify these charges, in part, by the use of ICD-9 codes that indicate why the patient needed the medical care. It bears noting that, while the US is still using the ninth version of ICD, most of the rest of the world is using the tenth version (ICD-10).
Historical Perspective
Most of the rules for billing and coding were developed by CMS, which was originally known as the Healthcare Financing Administration (HCFA). HCFA/CMS was born in 1977 and is an agency of the US Department of Health and Human Services. CMS oversees many programs, including Medicare, Medicaid, the State Children's Health Insurance Program, the provisions under the Health Insurance Portability and Accountability Act (HIPAA), and clinical laboratory improvement amendments. CMS is powerful because it is the single largest purchaser of healthcare in the US. Approximately one in every four Americans receives some CMS-related benefit, totaling more than 71.2 million beneficiaries. One of every three dollars spent on healthcare in the US comes through CMS. Because of the enormity of the cost implications, CMS is focused on making certain that dollars spent on healthcare are medically necessary and meet certain criteria for payment.
Fraud and Abuse
HIPAA, in 1996, and the Balanced Budget Act of 1997 gave CMS new tools and resources for “stepping up program integrity activities” to deter and detect fraud, waste, and abuse within the system. Because funding for the detection activities is self-perpetuating, the agency has financial motivation to recover funds from fraudulent activities. CMS directs physicians to use certain codes to indicate services and disease states so that it can better track the utilization of medical care and provision of payments. All payers in the US now use the same coding systems. Therefore, all providers who intend to bill for medical services in the US must use the appropriate codes and are obligated to understand and obey the rules regarding medical necessity, billing, and coding.
Coding Systems
Current Procedural Terminology.
Current procedural terminology was developed in 1966 by the American Medical Association (AMA) as a means of assisting physicians in identifying certain procedures that they perform for patients. The first stand-alone version of CPT was written in 1977. Since then, it has gone through several major and yearly minor revisions. The version in use at this writing is CPT-4, with CPT-5 expected since 2003, but not yet published. (It is important to use the revision for the current year, indicated as CPT-200X.) The use of CPT is mandated by CMS for clinicians to describe services rendered to patients. It is a collaborative effort of the AMA and CMS. The yearly additions, deletions, and revisions to descriptions of services and procedures are overseen by the AMA CPT editorial panel, with input from the CPT advisory committee. The CPT editorial panel is comprised of 17 members. Eleven of these are physicians suggested by various medical specialty societies (therefore, a pediatrician is not always on the panel); the other members represent CMS, Blue Cross and Blue Shield, the American Hospital Association, America's health insurance plans, performance measures development organizations, and the CPT advisory committee. The CPT advisory committee is a 90-member group with representation from the majority of major physician organizations, such as the American Academy of Pediatrics (AAP) and the Society of Critical Care Medicine. Member organizations must be members of the AMA house of delegates or the Healthcare Professionals Advisory Committee.
Table 6.1 RVU for commonly used CPT codes in pediatric critical care
CPT code Descriptor Work RVUs
99291 Hourly critical care, first 30–74 mins 4.5
99292 Hourly critical care, each additional 30 mins 2.25
99293 Pediatric critical care (29 days—24 months), initial day 15.98
99294 Pediatric critical care (29 days—24 months), subsequent days 7.99
99295 Neonatal critical care (less than 29 days), initial day 18.46
99296 Neonatal critical care (less than 29 days), subsequent days 7.99
99289 Pediatric critical care transport, up to 24 months of age, first 30–74 mins 4.79
99290 Pediatric critical care transport, up to 24 months of age, each additional 30 mins 2.40
99221 Inpatient care, initial, lowest level 1.88
99222 Inpatient care, initial, moderate level 2.56
99223 Inpatient care, initial, highest level 3.78
99231 Inpatient care subsequent, lowest level 0.76
99132 Inpatient care subsequent, moderate level 1.39
99233 Inpatient care subsequent, highest level 2.0
99440 Newborn resuscitation 2.93
Data from Centers for Medicare and Medicaid Services. Medicare program: Revision to payment policies; final rule. Federal Register. 2006;71:69624–70251.
CPT is divided into six sections of 5-digit codes. The sections that pertain most to pediatric critical care practitioners are found in: “Evaluation and Management (E and M),” which has no procedures but describes most of what we do; “Surgery,” which includes some of the procedures we perform; “Medicine,” listing most of our common procedures; and “Anesthesia,” which is used by some individuals in some states to bill for sedation services beyond moderate sedation. Each section of the book is preceded by written guidelines that contain the rules that the clinician must follow to bill and document correctly and to avoid being charged with fraud and abuse. Each section is further divided into subsections. For example, the E and M section contains (among others) the following subsections: office and outpatient services, hospital services, consultations, emergency department, critical care services, and neonatal intensive care. Any practitioner who is planning to bill for services must be acquainted with the content of those areas that pertain to her practice. It would be impractical to reiterate all of the rules in this chapter, although the major issues for pediatric critical care will be discussed. Because a new version of CPT, with the potential for new rules included, is published each year, the clinician must seek out the most current version available on a yearly basis. Although the AMA owns the copyright for CPT, books describing the codes and the rules that govern their use may also be obtained from other sources.
Relationship of Current Procedural Terminology to Clinician Reimbursement.
CPT codes are related to reimbursement for clinical services through a mechanism known as the

resource-based relative value scale, which assigns a relative value unit (RVU) to each item that has a CPT code. This scale was developed by the Harvard School of Public Health in the mid-1980s, under a government mandate. It was introduced into clinical practice in 1992, the year that CPT codes for E and M services were introduced, and detailed instructions for using the codes were added to the CPT book. Each CPT code is assigned a number of RVUs that are used to determine payment through Medicare, but they may be used by other payers as well. RVUs are reviewed by the AMA/Specialty Society Relative Value Scale Update Committee. This committee advises CMS on what value should be associated with each CPT code. However, CMS is not obligated to follow the advice provided. Three components comprise an RVU: physician work (PW), practice expense (PE), and professional liability (PL). In addition, a geographical variation is provided to accommodate the variations in the cost of living in different regions of the country. This variation is linked to the geographical consumer-price index (GCPI). The general formula for calculating reimbursement under Medicare is:
The conversion factor (CF) is necessary to convert the general formula to the actual dollars paid per service. The CF must be changed yearly to maintain what is known as “budget neutrality” in case any changes in the codes, valuations, or numbers of Medicare recipients would result in a total increase of more than $20 million in any one year. For calendar year 2007, however, the formula contains a new factor, the budget neutrality (BN) adjustment, which has the effect of decreasing Medicare physician reimbursements by ~10% (7). The 2007 payment formula is:
The value of BN for calendar year 2007 is 0.8994. CMS chose to apply the BN adjustor instead of adjusting the CF downward because the potential budget overrun was due to changes in physician work RVUs. If the CF had been changed, it would have had the effect of decreasing all elements in the reimbursement equation by ~5%. Many physician organizations are pressing Congress to revise the general formula for reimbursement, citing problems of access to care for Medicare and Medicaid recipients. As reimbursement per RVU falls, physicians are increasingly unwilling to provide care for these patient populations.
Revisions to RVU assignment can be made yearly, but they must be made at least every 5 years. Each year, in late November or early December, the RVUs for new, revised, and ongoing codes as of January 1 of the following year are published in the Federal Register. This publication also describes any new documentation requirements and changes to definitions of the CPT codes. The most recent physician work RVUs for some common pediatric and neonatal CPT codes are listed in Table 6.1 (7).
Although CMS oversees Medicaid and Medicare, it does not set the actual reimbursement rates for Medicaid, because this decision is left to the states. Consequently, the system contains a potential inequity, in that, in most states, the actual Medicaid reimbursement for any given CPT code is lower than the Medicare reimbursement for the same code. A 2007 report by the Public Citizen Health Research Group revealed that the average Medicaid reimbursement to physicians is only 69% of that paid by Medicare (25) and that the quality of care, scope of services, eligibility requirements, and reimbursements vary tremendously from state to state. The state and federal governments support Medicaid jointly, whereas Medicare is totally federally funded. Therefore, whereas the published RVUs and reimbursement formulas presented above are used as absolute reimbursement standards for Medicare, they are only used as guidelines for Medicaid, and private payers are not obligated to abide by the CMS guidelines at all.

To determine how much a provider will be paid under non-Medicare plans, a request should be made for a payment schedule from the local carriers, including Medicaid and the Medicaid health maintenance organizations (HMOs), as well as the primary private insurers in the area. The AAP and other child-friendly organizations have launched a campaign to educate legislators about the inequity in access to healthcare that arises due to poor Medicaid reimbursement rates. Many state AAP chapters are active in discussions with local legislators. Because most of this activity occurs at a state level, pediatric critical care practitioners are encouraged to work with their state governments toward ensuring that all children have access to the highest quality pediatric critical care possible by advocating adequate reimbursement to providers.
Coding for Diseases and Diagnoses
ICD-9 coding.
By choosing the appropriate ICD code, the healthcare provider tells the payer why the service associated with the CPT code indicated on the bill was provided. The international classification of diseases was developed by the World Health Organization for the storage and retrieval of diagnostic data for statistical and epidemiologic use. In 1950, the US Public Health Service and the Veteran's Administration tested the classification scheme for possible clinical use. In 1979, the then-current version (ICD-9) was introduced for use by hospitals and states for tracking data on discharge diagnoses and other topics. In 1988, the Medicare Catastrophic Coverage Act required physicians by law to submit diagnostic codes for Medicare reimbursement, effective April 1, 1989. CMS (then HCFA) designated ICD-9-Clinical Modification (-CM) as the required coding system. The next numbered version of ICD (ICD-10) was developed by the World Health Organization in 1993 and is in use in most countries but on hold in the US. It contains at least 5500 more codes, with new diagnoses, and is more user-friendly (more consistent with medical care and the way clinicians think about diagnoses). ICD-10 is alphanumeric and will require major changes to US computer systems, which will be very costly. Hence, although the lack of ICD-10 data limits the US in being able to compare its diagnoses with those of the rest of the world, the change is unlikely to occur until it is mandated by legislation. ICD-9-CM lists of diagnoses are published yearly, with changes taking effect on October 1 of the year before the designated year of the codes. For example, the 2007 version of ICD-9 took effect October 1, 2006. Recent additions pertinent to critical care include diagnoses such as severe sepsis and systemic inflammatory response syndrome. The 2007 edition, which represents the ninth version of ICD-9-CM, included over 300 total additions and revisions. Most of the time, the revisions are made to stay in line with current medical terminology. For instance, in 2007, the title for the diagnostic group for epilepsy (category 345.xx) was changed to epilepsy and recurrent seizures (5). This slight change may seem unimportant; however, medical personnel often use the term “seizure disorder” when describing a patient with epilepsy. In the past, if one documented “seizure disorder,” the diagnosis code would yield a term that was considered nonspecific by the payers and create a risk of nonpayment.
Most physicians and other providers receive very little training in diagnostic coding for the purpose of billing. Some basic guidelines can help the clinician to be more successful in clearly communicating the reasons for the provision of critical care or performance of specific procedures. In general, the first diagnosis reported should be the diagnosis primarily responsible for why that child needed that service on that day. It should be specific to the service provided by that subspecialty, especially if other physicians will submit a bill for an encounter on the same day. When choosing a code, the clinician should think as specifically as possible and imagine an auditor for the payer looking at the CPT charge, for example, for the first hour of critical care for that day. A primary diagnosis should be chosen that explains why the clinician needed to provide critical care that day. For example, the patient with sickle cell disease, suffering from acute chest syndrome in the PICU on a ventilator because of hypoxemia, should have a primary diagnosis that is specific to critical care. In this case, the authors would choose “acute respiratory failure” from the list of all possible diagnoses and document that diagnosis in the chart. Based on medical training, the inclination is to list the underlying disease, such as sickle cell anemia, as the primary diagnosis. However, in justifying the need for medical care, the underlying diagnosis should be listed last, if at all. Currently, up to four diagnostic codes per patient per day can be listed on the form that is submitted to the payers. The most acute and most specific codes should be listed first.
Of equal importance is how the provider documents the diagnostic information in the chart. It is helpful to use language that can be directly translated to one of the ICD-9 codes. This is especially true when others are performing chart abstraction to obtain billing information and the provider is not actually choosing the codes. The abstractor can only choose a code based on what is written in the chart note for that day by the attending physician or by the resident and attending together (see below for a discussion of teaching physician rules in documentation). Therefore, if the patient has epilepsy, it should not be recorded as “seizures” or “convulsions,” because these are separate diagnoses. As noted earlier, however, the term recurrent seizures is now considered equivalent to epilepsy. Epilepsy is considered more specific than either convulsions or seizures and should therefore be used whenever appropriate to the child's condition. In addition, the provider should try to be as specific as possible in describing the condition. Without this information, the abstractors will be forced to resort to a nonspecific descriptor, and the true nature of the patient's severity of illness will be lost. In the epilepsy example, one would need to indicate whether the epilepsy is focal or generalized, intractable or not, and the like. It is useful, even in an abstraction situation, for the clinician to review the ICD-9 codes for commonly seen diagnoses to become familiar with the language used.
Table 6.2 Age and location relationship to specific critical care codes
Code Location Age
99289–99290 Transport, requires direct face-to-face presence of the attending physician 0–24 months
99291–99292 Outpatient Any
99291–99292 Any >24 months
99293–99294 Inpatient 29 days–24 months
99295–99296 Inpatient 0–28 days
99298–99300 Inpatient Weight-based
Data from American Medical Association. Current Procedural Terminology: CPT 2007: Professional Edition. Chicago: American Medical Association, 2006;696.
Some Specific Current Procedural Terminology Codes for E and M Services in the PICU
In 2005, a new code was introduced for billing pediatric critical care. However, the majority of pediatric critical care billing still utilizes the original hourly critical care code. Situations under which the provider should utilize each of the possible critical care codes will be reviewed in this section. In-patient hospital care codes are not discussed, although usually, a subset of patients in the ICU should more appropriately be billed with those codes. In addition, “bundling” will be discussed but not the specifics of the procedure codes that are or are not bundled with the various critical care codes. Any provider who is

billing for any service must become familiar with the rules and guidelines provided in the most current CPT book.
The major determinant of critical care billing in the US is the condition of the patient. Regardless of which code is used, the patient must meet the definition of critical care. For the purposes of CPT coding, a patient is considered to be critically ill if he has a life-threatening illness or injury and if some treatment option is being exercised to prevent worsening of that life-threatening condition. Patients may be critically ill and stable, but the physician must take care to document how the provision of care under the physician's direction is sustaining that stability. Patients who are in ICUs for monitoring purposes only and do not require interventions do not meet the definition of being critically ill. The mere presence of a patient in the ICU does not qualify that patient for consideration as critically ill. Patients may be critically ill for many days; they may be critically ill even if they have a do-not-resuscitate order. The definition of critical care has evolved somewhat over the years; the most current definition will be found in the current version of the CPT coding book (4). In addition to the requirement for the patient's condition to meet the definition of critical illness, the practitioner must be providing critical care. It is not adequate that the physician visits a patient for 5–10 mins, makes no changes in their life-sustaining therapy, and thinks that critical care has been provided to that patient.
Three basic coding families are used to indicate services provided to patients in the PICU; they depend on the patient's age and location (Table 6.2). Although they all depend on the patient meeting the criteria for critical illness just described, the requirements for physician attention vary by code; therefore, the physician's documentation should be completed accordingly.
The Hourly Critical Care Code.
The basic hourly critical care codes, 99291 and 99292, are used to bill critical care services for patients older than 24 months through adulthood. These codes may be used in any location and are the only codes that can be used in an outpatient setting (such as the emergency department). The rules for using these codes are the same, whether the code is used in adults or children. Specifically, direct time spent by the attending physician is counted (time spent by a resident or fellow alone does not count). The practitioner who is billing must give her full attention to that patient for that period of time and therefore cannot provide care to other patients at the same time.
The time spent with the patient includes time spent reviewing labs and radiographs (as long as this is done in the unit), time discussing the case with other physicians (not residents or fellows), and time performing documentation, in addition to the examination and treatment. Although it is an hourly code, the physician should document and bill for a total amount of time spent with that patient on that day. The CPT guidelines specify how the time is to be counted. For example, the first 30 to 74 mins constitutes the first “hour” of critical care. Charts of how to count and bill critical care time are available in every CPT book. Any patient who requires less than 30 mins of critical care should be billed using regular inpatient hospital care codes.
Some procedures are bundled into the code and cannot be billed for separately. Bundled codes are codes for which a separate bill cannot be generated because it has been determined that they occur so often together; the RVUs for the main code have already been adjusted to account for them. For example, for 99291, the first hour of critical care, the procedures that are bundled when performed during the critical period include such activities as interpretation of cardiac output measurements, placement of nasogastric and orogastric tubes, and ventilatory management. For the procedures that are not bundled, such as placement of a percutaneous central venous catheter, the time it takes to do the procedure cannot count as both critical care time and procedure time. The provider's note should include a specific statement such as, “I spent X time providing critical care to this patient, not including time spent performing procedures.” Any unbundled procedures should then be billed separately. The use of modifiers will not be discussed in this chapter. However, the reader should note that in the situation just described, the proper billing of both an E or M code (critical care time) and a procedure code on the same day requires the use of modifier “-25” (4).
Time spent with family under this code requires careful justification—the accompanying note must specify that the time spent with family was because the patient was incompetent and that the discussion was directly related to the decision making for that day. Giving an update to family members, unless medical decision making occurs during that update, does not count toward the time. Time off of the floor or unit, even if it is directly related to the patient, also cannot be counted in the time calculation. The reason for this policy is that if the physician is away from the floor or unit, she cannot be immediately available to the patient.
Table 6.3 References and additional readings for critical care billing and coding
AMA CPT 2006, 2007, etc. American Medical Association 2005, 2006, etc.
AMA ICD-9 American Medical Association 2005, 2006, etc.
Coding for Pediatrics American Academy of Pediatrics Yearly
Billing and Coding in Critical Care Society of Critical Care Medicine 2006, every 2–3 years
The Global Codes.
The codes for pediatric and neonatal critical care (99293–99296) are considered global codes and are billed once per patient per day. These codes require that the patient resides in an inpatient setting (usually the PICU or the NICU) and meets the same definition of critical illness as listed earlier. They differ somewhat from the hourly codes in the requirement for physician interaction with the patient and, therefore, in documentation. The global codes require that the physician provide “personal direct supervision of the healthcare team in the performance of cognitive and procedural

activities.” These codes have more procedures bundled into them than do the hourly codes. They are divided into two families—one for pediatric (99293, 99294) and one for neonatal (99295, 99296) critical care. In each case, the first code listed is to be used for the first day of critical care, and the second code is used for subsequent days. It should be noted that, because 99295 and 99296 are for use in neonates, patients who are 29 days of age or older must be billed using 99293 or 99294. If a patient is in the hospital and is being billed using 99296 (neonatal critical care, subsequent days) for the first 28 days of life, on the day that the patient becomes 29 days of age, the provider must switch codes and bill under 99294 (pediatric critical care, subsequent days). If one continues to submit a bill for this patient using 99296 after the 28th day of life, most third-party payers will reject the claim.
Additional global codes that cover pediatric patients between the ages of 2 and 5 years and between 5 and 12 years have been proposed. Acceptance of these additional codes would require a complete renumbering of the sequence of critical care codes. The earliest a practitioner might see the new codes would be in 2009.
The practitioner should be aware of many more issues concerning billing for critical care services prior to submitting any bills. Additional reference materials are listed in Table 6.3.
Putting It All Together—The Superbill
To tell CMS or another payer both what service(s) were performed on a particular day and why the clinician provided that service, the provider must be able to code for both CPT and ICD-9. It is convenient to have a pre-made form holding most of the useful codes for that particular unit or group of practitioners on which the provider can easily check off what was done and why, thus requiring less work and time in finding the correct codes to meet coding standards. Such a form is generally referred to as a “superbill.” In some practices, it might be called an “encounter form.” The provider completes the form and gives it to the person or organization that will complete the official billing instrument that will be sent to the payers. Electronic methods, some handheld, are also available to permit comprehensive billing and coding for physicians (see Chapter 11). Of all approaches, a knowledgeable person or group of certified coders who provide chart abstraction will save the provider the most time, capture all documented services, and avoid problems with billing and coding compliance. An example of a 2005 superbill used in a PICU where the physicians are responsible for choosing correct CPT and ICD-9-CM codes is presented in Figure 6.1. The form is double-sided; Figure 6.1A represents the front of the form, with room for the patient identifier. It lists the commonly used CPT codes for 1 week's worth of interactions. All physicians in the group can bill using the same sheet for the week. At the bottom of the first page, space is provided for the patient ICD-9-CM diagnoses codes, which are obtained from the back of the form (Fig. 6.1B). The diagnostic codes are numbered, usually from 1 through 4, and those numbers are transcribed to the front of the sheet for that day. Because a patient's illness evolves over time, the order of the diagnoses as well as which are chosen for a particular day, usually change as the week progresses.
Compliance refers to the provider's understanding of and complying with all billing and coding rules, especially teaching-physician rules for those who work in an academic institution. Failure to meet compliance standards can lead to charges of fraud and abuse. Hence, chart documentation becomes critically important. The provider must document the patient's condition, the thought process that accompanied the evaluation, and the indications for any procedures that were performed. For hourly critical care services, it is essential for the attending physician to indicate, using the word “I,” how much time was spent providing critical care. For the global pediatric and neonatal services, no specification of time spent is necessary, because the physician is stating in her note the direct supervision of the healthcare team. Any diagnoses that will be coded by ICD-9 should also be mentioned in the chart.
Routine internal audits of physician billing activity can identify the need for additional education in billing and coding practices and should be performed routinely by the billing group. Routine audits and training will prepare physicians and other practitioners should an external audit ever be conducted. If internal issues are found and attempts at educating providers about correct coding are documented, external auditors will be more likely to classify identified problems as individual error rather than systematic attempts at fraud.
Recruitment and Retention of Intensivists
Building an ICU service requires staff. Chapter 5 identifies various members of the healthcare team who are important in providing appropriate care for patients in PICUs. This section is concerned with general approaches to hiring and mentoring individuals. It speaks mostly of physicians, but the principles are similar regardless of the type of healthcare provider being recruited. Physician leaders of critical care units must be cognizant of human resource issues when recruiting individuals to work in their units. Because hiring laws differ by country and region, and because of cultural differences between various places in the world, some of this discussion must be relatively nonspecific. When possible, appropriate references or



recommendations for additional reading are provided. The principles discussed here can be adapted based on the perspective of the country, region, or institution involved. No part of the following discussion is meant to suggest that national, regional, or institutional processes are incorrect; rather, we have tried to focus on best practices when available.
Figure 6.1. Example of a superbill from the year 2005 showing how billing and coding in the PICU can be facilitated by creation of a one-page instrument. Because of yearly modifications in both CPT and ICD-9-CM codes, this is only an example and cannot be used to actually bill. A: Front of bill, containing patient identifier information, CPT codes, and a place to indicate which diagnoses (from the back) are being used on that day. Physicians initial the specific charges and then sign at the bottom of the sheet. B: List of commonly used ICD-9-CM codes. These codes may be chosen and numbered, then the numbers transferred to the front of the sheet. Bold font indicates common critical care diagnoses; shaded boxes indicate nonspecific diagnoses that should not be used as primary diagnoses.
Figure 6.2. Algorithm of sequential steps in the recruitment and retention process.
New intensivists are recruited for one of two reasons: either additional staff are necessary due to program growth, or the program has sustained the loss of one or more intensivists. This loss may be due to a number of reasons, such as illness, retirement (becoming a more frequent issue due to the number of pediatric intensivists over the age of 50), or relocation due to family considerations. However, occasionally, the necessity to recruit is caused by a failure to retain a valuable member of the staff, generally due to unhappiness on the part of the physician caused by some component of lack of fit—whether on the basis of salary, job description, lifestyle, or dissatisfaction with the division head or chair (15). Because retention strategies seem costly, some groups, units, or universities do not engage in them as much as they should. However, the recruitment of new physicians is even more costly, especially when it occurs because of the failure to retain experienced, highly functioning members of the team. The cost of recruiting and training new faculty has been estimated to be one-and-a-half times the first year's salary (12). Therefore, plans for the retention of valuable physicians should be in place even before the recruitment begins. Successful recruitment begins well before an employment ad is created or a candidate is interviewed. Suggested steps in the recruitment process are indicated in Figure 6.2.
Establish the Need
To establish the need for the desired recruitment requires completing at least the rudiments of a business plan, the components of which will be discussed in a later section. The position must have a clear purpose, and the job duties must be elucidated. A source of funding must be established, as well as a salary range, which will vary by experience and specific job title. Will the person be doing anything other than clinical care? How much time is the candidate expected to spend on the job? Will the individual have leadership and administrative duties? What are the teaching commitments? Is research activity expected? If so, how is it to be funded? What will be the criteria against which the unit or department will measure success? It is wise to prepare a written, prioritized list of duties, expected outcomes, and desirable traits of the successful candidate before the recruitment begins. The unit or division director must also be aware of any specific rules for hiring physicians in the home institution. Most public institutions in the US, for example, are bound by strict human resources guidelines regarding gender and racial discrimination, as well as established guidelines regarding salary, benefits, title, and other issues. Failure to comply with human resources guidelines could invalidate a recruitment process. In many cases, specific permission must be obtained to “open” a position.
The Search Committee
Many intensive care unit directors, when faced with the need to recruit staff members, believe that it is not necessary to establish a search committee—that one is needed only for high-level recruitments. However, the authors suggest that having a search committee, even if it is only an informal committee, will help to establish the seriousness with which the search is undertaken and keep the process moving forward. We recommend establishing membership of the committee before the position is posted or advertised. Members of the committee should be involved in determining criteria and priorities in advance. The leader of the search (usually the unit or division director) should communicate his vision for the position to the committee. What type of candidate is being sought? What is this job? All major stakeholders should be involved in the committee; it should be comprised of most of the individuals who will be involved in interviewing the candidates.
A good committee contains individuals with different perspectives and areas of expertise. We recommend the PICU physician recruitment search committee contain representatives from the attending physician group (both prospective colleagues of the candidate and physician users of the PICU), nursing personnel, representatives from hospital or department administration, PICU fellows, and others as deemed appropriate. It is important for candidates to be given the opportunity to meet a wide and representative group of individuals, yet the number should not be sooverwhelming that they are left

confused at the end of the day. However, broad-based input will be most helpful in finding the right candidate who is the best fit for the institution and the particular situation.
Another issue important to recruiting the best candidate is ensuring appropriate diversity on the committee. This includes race and gender as well as position and role.
The search committee should meet to discuss the needs of the unit or division and to establish the position description. They should then formulate a timeline, working “backward” from the desired start date to allow enough time to obtain licensure, help with relocation, and attend to other related issues. Often, the need is immediate, necessitating that searches begin as soon as the opening is identified. The committee should decide on selection criteria, how candidates will be evaluated, and how feedback will be given to the committee chair. How will different qualifications be weighted? Will the position be advertised and, if so, where and how?
Using a Professional Search Firm
Increasingly, medical searches are being conducted by professional search firms. Sometimes, it is necessary or desirable to utilize one of these firms, especially if the position is one with significant leadership or extremely specialized expertise requirements. In addition, if the position is critical or has proved difficult to fill, the services of a search firm may be helpful. However, search firms are relatively expensive. Many require the payment of a flat fee that generally runs in the thousands of dollars, while others require some percentage of the first year's salary. Using a firm can be very helpful, but it does not absolve the person leading the search of all responsibilities. However, if the institution is inexperienced or if the physician leader does not have the time necessary to attend to all the detailed steps listed in Figure 6.2, using a firm may be the best use of available resources. Once the position has been advertised and responses have been received, some fraction of candidates will be invited to interview.
The Interview
The interview has three purposes: (a) it gives the search leader and committee a chance to evaluate the candidate, (b) it allows one to “sell” the division/unit and hospital or medical school to the candidate and, most importantly, (c) it provides the opportunity to test how well the candidate will fit with the culture of the institution or group that he will be joining. Failure to use the interview for all three purposes is a common mistake and one that may lead to hiring the wrong person. The “selling” of the institution or group is exceedingly important and must start before the candidate sets foot in the institution. Initial interactions with support personnel are important. The individual who handles the logistics of the proposed trip has a profound impact on the candidate, especially if things go wrong. The schedule must be comprehensive but not overwhelming. It is important to include time for breakfast, lunch, and dinner and to plan for some breaks in the schedule, allowing the candidate time to freshen up, collect his thoughts, make a phone call, and the like. The interview day should include a tour of the facilities. It is important to maintain clarity throughout the process. Everyone who is meeting the candidate should understand the position and why this candidate is being evaluated. They should be knowledgeable enough to answer basic questions and should know what to do with questions that they are unable to answer.
The interview day should be organized in a sensible fashion. A model agenda is listed in Table 6.4. In general, the day should begin with clear instructions on how the candidate will arrive at the medical center or ICU. We find it useful to have the division director meet the candidate in the morning for breakfast, to start the day on an informal note and to provide an overview of the program, the position, and the day. Efforts should be made to remain on schedule; hence, it is useful to plan some time between appointments, especially if the candidate is expected to travel from one office or building to another. One member of the host division or department should be identified to guide the candidate from place to place; alternatively, the candidate can be assigned to a conference room or open office, and those doing the interviewing can be asked to meet him there. The total length of the first visit can be from 1 to 1.5 days and should include dinner on either the night before the formal interviews or the night between the days. Because the candidate will not have his spouse or partner present at the first interview, the dinner participants should be comprised of representatives of the search committee. Often, the dinner is a good time to check for “fit” with the host division. A “wrap-up” session with the division head or unit director (whoever is leading the search) should be scheduled at the conclusion of the entire visit to establish next steps, obtain first impressions, and to give both parties the opportunity to ask any questions that may have arisen during the visit. The candidate should leave with the knowledge of how to obtain more information and answers to any questions that have not been addressed. It is also useful to clarify whether the candidate has specific time-sensitive issues that might affect his decision-making process. Any issues relating to spouse or family members should be discussed at this point (spouse must find a job, children must be enrolled in school, etc.). The leader must always keep in mind, however, that some questions should not be asked, because they might lead to suggestions of discrimination in the future, depending on the laws of the home country. Checking with the human resources office prior to conducting the interview can provide guidance on topics that may be considered “off limits.”
Table 6.4 Potential agenda for an interview day
Time Meet with Reason
7:30–8:30 Division head over breakfast Discuss overview of position, institution, and location. Provide orientation to the day, explain who the candidate is meeting and why
8:35–9:30 Join work rounds in PICU Obtain a glimpse of the way the team operates in action, see a cross-section of the types of patients in the ICU
9:35–10:00 Senior nursing members Chance to interact with nonphysician members of the team and interact with a group
10:10–10:30 Junior faculty member Obtain additional viewpoints, learn about how newly recruited members are treated, discuss items that might be important from a personal, social standpoint
10:35–11:00 Division administrator Review departmental/divisional support, benefits, etc.
11:10–11:50 Research faculty member Learn about research opportunities, obtain additional information
12:00–1:00 Nurse practitioners over lunch Learn about the nurse practitioner program, add another component to the team members
1:10–1:35 Non-PICU department of Pediatrics faculty member Learn perspective of outsider to how PICU functions
1:40–2:10 PICU fellowship director Discuss fellowship issues and obtain further insight into how the ICU works
2:15–2:45 Cardiac surgeon Discuss perspectives from a nonintensivist who utilizes intensive care services and is part of the team
3:00–3:30 Pediatric department chair (can sometimes wait for second visit) Obtain overview of department, learn what is needed for promotion and tenure if in an academic setting
3:35–4:00 PICU fellows Obtain perspective of trainees
4:00–5:00 Division head Wrap up, answer any questions, determine next steps and time frame. Share first impressions
5:00–6:00 Break Someone can drive candidate back to the hotel for rest and freshening up before dinner
6:00–8:00 Division members over dinner Time to test the “fit” of the candidate with the rest of the group. Will the candidate be comfortable with the culture and dynamics of the team?
Figure 6.3. Example of a typical faculty candidate evaluation form.
Making a Decision
Following the visit, efforts should be made to receive feedback from the members of the search committee and others who met with the candidate. A specific feedback form that is developed by the search committee and is specific to this particular position should be used; an example is provided in Figure 6.3. At this point, if numerous candidates seem appropriate to your needs, a second visit might be scheduled. However, this is not always necessary.
Once a tentative decision has been made, but before making an official offer, the candidate's references should be checked. It is useful if the division head or unit director conducts the reference checks by phone, even though the institution will most likely require written letters of recommendation to meet hiring, appointment, or credentialing standards. Checking of references must be done religiously. It is useful to call a variety

of individuals at the candidate's home institution or others who have worked with the candidate in a prior position. They should represent as diverse a group of individuals as the candidate is likely to work with in the new job. Calls should be made to the person's immediate supervisor, colleagues, and subordinates. At least one evaluation should be obtained from a nurse or allied healthcare worker.
Once the references have been called, it is important to reevaluate the committee's decision. Does this individual have all of the qualifications that were decided upon prior to the search? If not, what aspects take priority? Although the clinical needs might be significant, a person who is a poor fit will not be of value in the long run. The leader should be certain that both the candidate and the committee are clear on the candidate's capabilities and the needs of the job. Any areas of disconnect should be identified and addressed prior to moving forward. The most important question from the standpoint of the prospective boss should be, “Will this individual enhance the team already in place?”
Making an Offer
Making the offer can be the most difficult part of the process for both candidates and their prospective supervisors. It is very important for both parties to be sincere, open, and straightforward. Supervisors should not make promises that cannot be kept and should not make the job seem easier than it is. It is crucial that, at this juncture, the candidate have a clear understanding as to the expected on-call duties or likely number of hours worked per week. The candidate must be able to trust the information provided by the supervisor. An employee who arrives to find that work expectations are considerably higher than presented will soon develop mistrust and resentment. If the truth will dissuade the chosen individual from accepting the offer, it is better for the division head or unit director to know that and move on to another candidate. Likewise, candidates should not misrepresent their interests or willingness to perform tasks that they would rather not do in an effort to obtain the position.
Table 6.5 Differences between “Baby-Boomers” and “Generation-X”
  Generation Xers Boomers
Work–life balance Willing to work hard but only if balance can be achieved Work hard out of loyalty
Relationship to job/Institution Expect to change jobs frequently Expect long-term job security
Recognition of need to “pay dues” Not felt to be relevant to future career development Expect to do this for success
Willingness for self-sacrifice Will endure this occasionally See self-sacrifice as virtue
Response to authority Question authority Respect authority
Adapted from Bickel J, Brown A. Generation X: Implications for faculty recruitment and development in academic health centers. Acad Med. 2005;80:205–210.
In most cases, a verbal offer should be followed by a written letter or contract, which should include a statement of expectations for job performance. The letter or contract should identify all sources of support for the physician—not only the salary. In most cases, it is also important to document the expectations for “citizenship” in the group as well as specific responsibilities. Depending on the local rules or customs, the contents of the offer letter/contract may be predetermined, and the boss may have little ability to craft it. In that case, it may be helpful to write an addendum that includes all of these details. Legal advice may be necessary before any written document is sent to the candidate.

Once the preferred candidate is identified, recruited, and hired, the process must begin to develop and maintain job satisfaction for the employee. In academic medical centers, physician retention and faculty development are synonymous. The techniques developed in academic medical centers may be useful in other practice situations. In general, physicians are seeking a supportive environment, with transparent operations, in which data are shared. They want their contributions to be recognized. Salary, although important, is not the most critical factor in providing for faculty satisfaction. Trust and communication

with the immediate supervisor in the academic medical center are important (15) and, similar to studies of worker satisfaction in other industries, barriers to effective communication should be identified and removed.
Mentoring enhances retention; this is especially the case in the academic center but can be equally important in the practice setting. Mentoring establishes a welcoming environment for the newly hired, helps them to feel that they are part of the community, and fosters their ability to develop a career while more rapidly learning the culture and norms of the group. Increasingly, however, mentoring and coaching techniques that worked “in the old days” are proving to be no longer effective, as organized medicine deals with the impact of the “generation Xer.” The term “generation-X” refers to the cohort of individuals born between 1963 and 1981. This is the generation of most newly trained individuals and junior- to mid-level faculty. Certain qualities have been identified that distinguish the generation-X members from the “baby boomers” (born between 1945 and 1962), who still hold most of leadership positions within the field of medicine (12). Major differences exist between these two groups in attitudes toward work-life balance, importance of the job or institution to the individual's sense of overall well-being, willingness for self-sacrifice, recognition of the need to pay one's dues, and response to authority (Table 6.5). If mentors (who are generally in the baby-boomer group) are unaware of these characteristics of the generation-X individuals whom they are trying to mentor, the relationship may not be as productive or as helpful as it could otherwise be.
The International Campaign to Revitalize Academic Medicine has identified a crisis in academic medicine in Great Britain and Europe (18,29), as well as in developing countries, due to physicians' desire for flexible schedules, among other things. The retention of physicians in high-stress, high-demand subspecialties such as pediatric critical care will depend on our ability to meet the needs of this group of young physicians. Both how our jobs are structured and the mentoring and other support offered to physicians must take these differences and requirements into account.
Physician Productivity
Historically, pediatric critical care evolved in the world of academic medicine. Until recently, the approach of many academic medical centers toward practice management and fiscal responsibility was laissez faire. Issues related to business—contracting, coding, billing, malpractice—are still not routinely taught in pediatric critical care fellowship programs. It is still quite possible for a fellow to complete training and remain unfamiliar with the issues described in this chapter.
Improvements in information technology and a highly demanding reimbursement environment have made attention to clinical productivity both possible and necessary for pediatric intensivists. More hands-on care is provided by attending academic intensivists at the bedside now than was the case at the time that this text was last published. As the style of their practice has changed, academicians have adopted an interest in coding and reimbursement that used to be the sole purview of those in private practice. To justify additional intensivists, adequate salaries, and productivity-based reimbursement to medical and administrative leadership, pediatric intensivists should be conversant in the language of productivity and tools to ensure its optimization.
Defining Clinical Productivity
Perhaps the simplest method of defining an intensivist's productivity is a volumetric measurement of clinical activity. A director of a PICU should be able to describe the activity of the unit as a whole, and of individual intensivists specifically, in terms of admissions, procedures, average daily census, average length of stay, resource utilization (e.g., extracorporeal membrane oxygenation, ventilators, and inotropic support), risk of mortality (PRISM III or PIM2), and similar topics. Daily entry of patient information into an institutional and/or multicenter database, such as the Virtual Pediatric Intensive Care Unit, provides a tremendously valuable source of data that is highly understandable to medically savvy and lay people alike.
Professional activity is usually described in terms of a fraction of a full-time equivalent (FTE), whereby a 1.0 FTE is carrying a “full” clinical load. Because the standards for “full time” work vary by institution, other useful descriptors include time on-service, frequency of night and weekend call, and clinical hours worked per week. Because much of an intensivist's practice occurs when colleagues from other specialties are out of

the hospital and asleep, these facts may be persuasive during attempts to justify additional FTEs.
When a patient's bill is generated, the amount of the charge is recorded by the billing agents and may be reported to the physicians on a weekly, monthly, quarterly, and/or yearly basis. The actual amount billed is arbitrary and may be set by the physician group or administrators; therefore, it does not directly relate to the amount of work performed by the intensivists. Collections are generally counted on monthly, quarterly, and yearly bases. Dividing the total amount received by the total amount billed determines the gross collection rate. This parameter is only a weak measure of productivity for a number of reasons. To a large extent, the price paid is at the discretion of the third-party payer or is determined by CMS, as described earlier. The net collection rate takes into account contractual relationships with third-party payers and patient demographics (self-pay, commercial insurance, government programs). Contracted reimbursement is often negotiated and based on a multiple (or fraction) of the current Medicare reimbursement for an RVU. The net collection rate will almost always be higher than the gross collection rate. The net collection rate is calculated by dividing the amount received by the amount that should have been collected for that time period. Efficient billing processes will yield net collection rates in excess of 90%–95%, meaning that the office is collecting almost every dollar that is allowable by the particular payer. Patients without insurance are known as “self-pay patients” and are unlikely to be able to pay the entire amount billed for a stay in the PICU. Therefore, a high percentage of self-pay patients will significantly decrease the net collection rate, unless the bill is determined to be uncollectible and is officially written off. The net collection rate, although a good estimate of the effectiveness of the billing office, is a poor measure of physician productivity. However, for physicians in practice who receive no subsidies from the hospital, the various collection rates are very important. Net revenue, or the amount of money remaining after all practice costs have been considered, will be the best measure of productivity in this situation. However, for physicians in hospitals and academic medical centers, other, more reliable measures of productivity have been developed.
Relative Value Units
As noted in the section on billing and coding, every CPT code is assigned a value by the CMS that is described in terms of RVUs. In theory, complex medical decision making and technically difficult procedures are tied to higher RVUs (1,2). Given the consistency of work RVUs across settings, this measure is typically used to benchmark and describe productivity. It is important to note that RVUs do not necessarily translate directly to revenue. As also noted in the section on billing and coding, CMS annually assigns a uniform national conversion factor (in dollars) to the reimbursement formula. For non-Medicare insurers, payment is set at the payer's discretion. Most third-party reimbursement is negotiated as a percentage of the value of an RVU (16,19).
Benchmarking Productivity through Measurement of Relative Value Units.
Work RVUs are the most commonly used unit of productivity for benchmarking physician clinical activity. Benchmark figures are available through professional organizations (e.g., American Association of Medical Colleges) and private consulting companies. Benchmarking is usually reported in terms of upper and lower quartiles and the median for a 1.0 FTE. Consulting firms will provide information that categorizes performance based on unit characteristics—number of beds, number of intensivists, academic versus community setting, and the like. Given the relatively small number of PICUs nationally, it is common for external benchmarking to inaccurately describe a particular practice's patient population.
For example, pediatric intensivists may staff two 10-bed PICUs in the same city. One unit may care for a robust neonatal cardiac surgery population, while the other has an active bone marrow transplant program. The cardiac unit may generate more RVUs per patient day because of the relatively high RVUs associated with the global CPT codes used in patients <2 years of age. A comparison of the RVUs produced by a cardiac intensivist versus one who works primarily in the oncologic ICU could be misleading in terms of clinical effort.
Additionally, because the benchmark data available are presented normalized to 1.0 FTE, certain elements of error may be introduced in the calculations. The definition of how much work is performed by a full-time intensivist (1.0 FTE) varies from center to center. It is not possible to compare the effort based on hours per week, weeks of service per year, or other terms, because a clinical service can be organized in many different ways. The addition of trainees and students may alter the relative time one spends in direct patient care but may make this a parameter that is difficult to adequately measure.
Experience has shown that the most useful benchmark for productivity is within each institution. One of the authors (JMH) has developed an internal approach to benchmarking that has enhanced productivity at his institution. In this system, each pediatric intensivist's RVU production is benchmarked against the others and against the individual's performance over the previous 2 years. This approach is described in more detail here.
Maximizing Productivity at One Institution
Timely Billing.
Pediatric intensivists bill for a wide variety of services in different circumstances—global critical care, time-based critical care, procedures, sedation, transport, dialysis, extracorporeal membrane oxygenation, etc. The clinical pace and patient turnover is frantic in most PICUs, and it is very easy for the attending intensivist to forget what services were provided to each patient on a given day. When the author's (JMH) institution implemented a mandatory daily billing strategy, physician RVU production rose by 10%.
Concurrent Coding.
Daily review of the medical record, in conjunction with timely billing, increases measured productivity. In the just-mentioned approach, a coder, rounding daily to compare documentation in the medical record with physician billing, has the ability to identify clinical activity that the physician neglects to bill, find inadequate documentation (e.g., time not noted) to substantiate a code, and identify patients for whom the intensivist forgot to bill altogether. The initiation of this program increased RVU production by an additional 10%, decreased the denial rate from 5% to <1%, and decreased the overtime hours in the billing department.

Information Sharing.
Physicians are goal-oriented, data-driven, and competitive. Sharing comparative productivity data within a group of intensivists can be a highly productive or destructive experience. Punitive use of this data can destroy trust and collegiality within a group. The author (JMH) developed a mechanism by which this information is shared in the form of individualized charts on a quarterly basis. Each intensivist is able to identify her performance, while her colleagues' data is de-identified. The experience in this situation was that variance between high and low performers narrowed at the same time that overall productivity increased.
Correct Coding
In some circles, “correct coding” is synonymous with maximizing productivity. It is crucial that physicians, coders, and billing personnel receive regular updates on relevant CPT codes and their correct use. Both systematic undercoding and overcoding are unethical and illegal.
Aligned Incentives
Monetary bonuses based on productivity have proved to increase billing and RVU generation in a number of settings (5). If this strategy is employed, even greater attention to detail than normal must be paid to ensure that coding is in compliance with national standards. Nonmonetary incentives for productivity can be effective. These can include additional nonclinical time, hiring mid-level providers to support clinical activities, or purchasing an interesting but nonessential technology for the PICU.
Nontraditional Measures of Productivity
Historically, discussions of physician productivity were linked exclusively to professional revenue/RVUs. It is increasingly apparent that physicians in general, and intensivists in particular, make tremendous contributions to their hospitals. Clinical and financial symbiosis between pediatric intensivists and hospitals has spawned a number of creative measures of productivity. Pediatric intensivists are indispensable for clinical program development and financial health in modern children's hospitals or departments of pediatrics within general medical centers. As such, it is justifiable for pediatric intensivists to negotiate for financial support from their hospital in excess of professional revenue.
Contribution to Hospital Revenue
As mentioned earlier, in the discussion on billing and coding, in general, hospitals are paid a fixed amount for an admission based on the DRG associated with the patient's illness. The hospital is paid the same amount regardless of whether the admission is 2 days or 2 weeks. A hospital's economic survival is usually based on razor-thin margins of 3%–5%. Intensivists who provide efficient management that decreases length of stay and cost per case can make the difference between a positive or negative contribution to the organization.
Investigators found that an academic, adult ICU accounted for 24% of the institutional profit margin (11). At the Children's Hospital of the Cleveland Clinic, the contribution margin for admissions to the PICU is four times greater than for admissions to a regular nursing floor.
Some third-party payers have begun to pay hospitals more for more complex cases. All-patient redefined (APR) DRG severity-adjusted indicators (complexity, concurrent diagnoses, length of stay, cost per case, readmission rate) are used to justify higher levels of payment. Accurate calculation of APR DRG severity depends on accurate physician (intensivist) documentation. Physicians who are motivated to fully document their patient's condition contribute substantially to the hospital's financial health.
Quality Improvement Activity
Hospitals are motivated to provide safe, high-quality care for humanitarian reasons. They will also be increasingly financially driven to do so. In 2003, the CMS initiated a demonstration project that financially rewarded hospitals for excellence in five areas (10). This trend, termed “pay for performance,” will play a prominent role in healthcare reimbursement for the foreseeable future. Intensivists can have a significant effect on hospital quality (14). Our specialty's contribution to the “quality” movement may rank as a uniquely important form of productivity.
Subsidy for Vital but Poorly Compensated Services
Pediatric intensivists are uniquely qualified to provide procedural services that are clinically vital but not necessarily well compensated in professional revenue. Vascular access and procedural sedation are prime examples of these services. Hospitals may choose to recognize and encourage these activities by pediatric intensivists for a number of reasons—dedication to a pain-free environment, technical revenue associated with these services, or freeing other physicians (primarily anesthesiologists and surgeons) to engage in very lucrative activities. It would be reasonable for an intensivist leader to expect institutional financial support for his group to provide a very poorly compensated but necessary activity.
Productivity Related to the Academic Mission
Intensivists who practice in academic medical centers have more missions than the clinical one described earlier. Measures of productivity must therefore take into consideration the teaching, research, and administrative roles held by these physician-faculty members. Various schools of medicine have developed paradigms to identify and track faculty productivity based on hours of teaching, size of grants awarded, numbers of papers published in peer-reviewed publications, and similar parameters. The term mission-based management has been coined to describe the alignment of how faculty members spend their time with how they generate income and how they are paid. It developed during the late 1980s and early 1990s as a way to identify the financial sustainability of academic medical centers in the face of falling clinical reimbursements, increased government regulations, and diminishing support for the teaching and administrative missions within schools of medicine (22). In the academic medical center setting, productivity and performance must be based on more than a physician's clinical activity and an estimate by the physician as to time spent teaching, conducting research, and performing administrative duties. Various approaches to measuring productivity in these areas have been developed. They are not simple, and must be crafted to meet the needs of individual centers and to support the specific cultures of those centers. Because of the complexity of this issue and the wide interest on the part of chairs and deans in

further developments in this area, the Association of American Medical Colleges, in 2002, produced a management series on mission-based management, which is available free of charge on the Internet at
Performance Evaluation and Feedback
Earlier sections addressed issues of recruiting and retaining physicians as well as ways to measure physician productivity. Another major area of great importance to the longevity of any division or unit is the method used to evaluate the performance of the intensivists. Many approaches can be taken but, in general, an evaluation process must be initiated that is fair, comprehensive, and conducted on a routine basis. Just as productivity should be measured according to the physician's various activities, the performance evaluation should include all areas in which the physician participates. Best practices suggest that goals and objectives for performance should be established at the beginning of the period, that these goals be given weights and priorities, and that the person being reviewed be aware of and help to develop the performance review criteria in advance.
Areas to be evaluated should be tied to the job or position description whenever possible, emphasizing the need to make the job description truly descriptive of how the individual will spend his time. If the physician is to be evaluated on the success of a new program he was to develop, program development should be in the job description. Establishing clear expectations helps to improve performance. In the business world, much is made of the inclusion of “stretch” goals to push individual productivity and performance to the greatest possible heights (26). A stretch goal might revolve around program development, meeting specific safety objectives, or obtaining a certain amount of research funding. Whatever is determined to be appropriate for the individual should be identified, with clear parameters and metrics provided so that the intensivist can know whether or not the goal was met. Participation in quality-improvement activities, such as Six Sigma (21), involves setting stretch goals and finding ways to meet them.
Increasingly, organizations are utilizing the “balanced scorecard” approach to evaluate individual and team performance. This technique combines different types of indicators of performance into an overall snapshot of the individual's contributions to the organization's well-being. Other organizations are relying increasingly on 360-degree feedback to evaluate the individual's perceived strengths and weaknesses by obtaining input from peers, trainees, supervisors, patient's parents, and allied healthcare workers.
Regardless of the format for formal performance review, it is essential that the individual be given feedback concerning how he is doing. The leader must strive to do this regularly and objectively. Although the meetings need not be formal, they should be conducted in a professional manner. Constructive feedback should be provided. This is important for new members of the group as well as for those who are more seasoned. This is a challenging aspect of leadership for many medical directors and division heads, but if it is done routinely and in the fashion described, it need not lead to anxiety and agitation. Providing feedback on an ongoing schedule is a much better practice than providing it once per year, when the performance review (and potential salary) is being discussed. In addition, it helps to establish an appropriate relationship between the physician and the leader.
Developing New Programs: Writing a Business Plan
An essential component of any business is growth; it is therefore imperative that medical professionals develop a clear sense of how to propose new programs and see them through to completion. Most often, administrators and chairs will request a business plan when a faculty member suggests starting a new program or project, such as developing a transport team, starting a sedation service, or hiring new or additional staff.
The purpose of a business plan is to elucidate the reasons to institute the program, identify the costs (in time, financial and human resources, and space), and calculate projected benefits. Although the simplest of plans can be communicated verbally, under most circumstances, the plan should be written, presenting the appropriate substantiating data and references or resources from which assumptions were made. Being asked to prepare a business plan should not induce fear. One does not need a business education to write a viable business plan. However, the use of some standard business approaches may make it easier to communicate needs and expected benefits more clearly to nonclinical individuals who may hold the key to obtaining approval or funds for the program. If pediatric intensivists want to effectively compete for their department's, school's, or hospital's limited available investment dollars, the business planning must be convincing and carefully done. Data and business information are important but should not overshadow the ideas on which the plan is based. Although the numbers are essential to demonstrate that the physician has a concept of what is achievable and how much it will cost, the numbers alone are unlikely to be the critical determinant of whether the proposal will gain acceptance.
The why of the proposal is at least as important as the how or the how much. Key investors (chair, chief executive officer, dean) will need to understand the importance of the project and to be convinced that it is necessary; as well, they will have to be convinced why a particular person or team should be managing the project. What historical factors point to one's ability to take responsibility for a project like this and succeed? Looking at the project and the proposal from the perspective of what an outside investor might want to see will help to clarify and crystallize the major points. The following suggestions will increase effectiveness and creativity of thought and presentation.
The most important piece of the business plan is the planning that happens before any words, tables, or figures appear on paper. The starting point of the planning must allow the planner to answer the questions “What do you want to do?” “Why and how do you plan to accomplish it?” and “How much will it cost?”
The answers to these questions should be based in the organization's or unit's strategic plan. The strategic goals should be

aligned with those of the parent organization (hospital, group practice, or medical school) in which the unit or group exists. If the goals are not aligned, the plan is unlikely to achieve buy-in from the upper-level decision makers. Therefore, the plan must start with a clear and compelling mission, vision, and goals. These should be in writing and should reflect input from the appropriate team members and other stakeholders. The plan being proposed must support the mission and vision of the unit/group and must clearly relate to the accomplishment of at least one of the stated strategic goals of the unit/group.
The proposed project must be important if significant resources are being requested to make it happen. The more expensive it is expected to be, the more important it should be to the organization. How do you identify what is important? As mentioned earlier, alignment with the organization's strategic plan is the first step. If the proposed project supports a local, regional, national, or international need, especially one endorsed by a prominent organization, it rises in importance. If local supporters are vocal in identifying the need, the organization's leaders will be more inclined to listen.
A good plan starts with a good idea—one that is either unique in its approach to the problem being addressed or provides “a better mousetrap.” “Better” can mean “cheaper,” but this does not necessarily have to be the case. If it is not cheaper, it must have a better return on investment (ROI). What will the parent organization get for its investment in resources (human resources, space, capital)? A commonly sought ROI might be market share or revenue, but these alone will not be enough. Will you be meeting or exceeding published benchmarks in serving a particular patient population? Will you be delivering a new service that does not currently exist in your community? How big is the need for that service/unit in the community? Will you be competing with other units or institutions to provide this service, or will the new service bring you into a “blue ocean” (20), where you can operate away from the competition?
Occasionally, the business plan is required for relatively mundane reasons, such as the need to hire an additional physician for the group. In this case, approval is usually (but not always) assured, and the sponsoring organization simply needs to “see the numbers” to understand the costs involved. However, even here, approval will be much more likely if the stated plan can align the proposed recruitment with overall organizational strategy and highlight how the recruitment will add value to the group. Is there a particular skill that would be useful for your group to possess? Does this relate to changing patient characteristics (such as the care of patients receiving a new service—for example, liver transplantation) or evolution of the standard of care? It is useful in such situations to identify how the field has changed since the last recruitment was undertaken and to explain why this new expertise is required to continue to provide state-of-the-art care for the children who are admitted to the unit.
One should never take for granted that resources will be made available for any project, even replacement recruitments. The authors believe that, to be successful, every request for resources must be accompanied by a well-thought-out, written plan that carefully articulates the need, the reason, the method, and the expected ROI. The plan should include a method by which to monitor or judge success. It should include a parameter or parameters that are straightforward and easy to measure. The general expectation is that at least a one-for-one ROI will be appreciated by the end of a 3- to 5-year period, although these expectations vary with the particular circumstances. Sometimes a service is necessary but will not lead to enough specific direct increase in revenue to achieve the stated goal. In cases such as these, it may be useful to look at “downstream” revenue, or the ripple effect of the proposed program on admissions for other services, the enhancement of research opportunities, improved educational experiences, and similar issues. Because these metrics can be difficult to measure, some indicator of success should be agreed on prior to the start of the project.
Obtaining the necessary data to include in a winning business plan can be difficult. It is usually necessary to partner with a representative of the hospital's or medical school's finance or marketing office, so that a baseline can be obtained for market share, length of stay, profit and loss, or whatever parameter one is planning on improving with the proposed program. Having appropriate baseline data is essential. Chief executive officers, department chairs, and deans will want to know the source of the data, how the competitive analysis was performed and which assumptions were used, and how the proposed program metrics will demonstrate success. The more succinctly and directly these questions can be addressed, the greater the likelihood that the upper-level decision makers will be able to accept the plan as presented.
For areas in which data may not be readily available or the data are unable to prove the point, obtaining buy-in and written testimonials of support from appropriate stakeholders will be essential. Even if the data are available, the use of strategic stories can be very helpful (23). The multinational company, 3M (creator of the Post-it note, among other innovations), developed the art of “strategic story telling” into a corporate cultural approach to business planning (27). They believe that the ability to tell a compelling story in narrative instead of bullet points requires the author to understand the strategic logic of the proposal in intimate detail. This, in turn, allows the reader to understand in more depth the entire business situation. The following components are further suggested to produce a well-executed strategic story (27): First, set the stage by describing the current situation, the details of the status quo, who the players are, and what relationships exist in the field. Next, introduce the dramatic conflict. In this section, the author identifies the challenges faced by the group or unit and the critical issues that are obstacles to success. Finally, the story must reach resolution by following a logical argument that is specific to the current situation. If the plan is written well, the reader will be able to understand the vision of the author and her group. The intentions and the markers of success will be clear.
Table 6.6 A potential approach to organizing a written business plan
Component Purpose
Executive summary Makes the case for whatever is being proposed in a one- or two-page summary. May be the only part read by the main decision maker.
Introduction and overview Introduces reader to the PICU and the topic. Provides a glimpse into benchmarking this PICU against others in the city, region, or nation.
Business concept Presents the project the author wants to do. Ties the proposal to the strategic goals of the unit and the institution.
Market analysis Provides an understanding of how many children may need the service being proposed. Describes the current demand and the likely supply over time.
Competitive analysis Identifies the internal and external competitors. Demonstrates author's understanding of the entire field and potential problems.
Business strategy Shows how the author plans to overcome the competitive threats and meet the identified needs. Provides metrics to determine success.
Financial plan Provides a clear estimate of the financial resources required to initiate and complete the plan, as well as an estimate of the return on investment for the institution or backer.
Operations plan Indicates the operating capacities of the leader to achieve the stated goals. Identifies additional personnel and space required. Has a clear demonstration of author's responsibility to the project.
Summary Provides a concluding statement pulling together the initial vision with the proposed outcome. States clearly what the proposal will accomplish for whom and in what manner.
Tables and graphs Presents substantiating data that is not needed within the body of the proposal but might be needed to justify issues raised.
Adapted from Cohn KH, Schwartz RW. Business plan writing for physicians. Am J Surg. 2002;184:114–120.
Writing the Plan
Regardless of the approach taken to writing the business plan, the outcome must be a document that is clear, easy to read, logical, and can stand alone in support of the proposal. One potential format for organizing a written business plan is presented in Table 6.6. The components are described in more detail here.
The Executive Summary
The executive summary will be the first thing the reader sees and probably the only part that the reader remembers. It might

be the only part of the written plan to be read by a busy chief executive officer, department chair, or dean. It therefore must be a well-written, one- or two-page (the shorter, the better) summary of the salient features from the other sections of the plan. Because of its importance, it should probably be the last thing written. It must be consistent with the entire plan and make the case for the project being proposed.
Introduction and Overview
The Introduction and Overview is a relatively short section of the written plan that describes the unit or group and its history. One can include statistics on recent growth, current staff members, and, most importantly, the mission, vision, and goals of the group. The introduction sets the stage for the rest of the plan and helps to tell the reader why this team is in a position to determine the needs of the community. Although boasting is not recommended, the plan can be strengthened by highlighting recent accomplishments by the physician or nursing staff, awards received, and similar achievements. It may be useful to provide some data that benchmark the unit with other PICUs in the city, state, region, or nation. Does this PICU serve a specific niche population? Are there specific geographic issues to consider? How is this unit of value to the rest of the organization?
The Business Concept
The Business Concept section is the heart of the proposal. What is the author planning to do and why (for example, beginning a sedation service)? What is the evidence for an unmet need in the community or patient population (for example, long waits for pediatric MRIs, frequently canceled tests, and unhappiness on the part of referring physicians, radiologists, and parents)? What is the value of what is proposed? (How much time can be saved from being able to do these tests smoothly? How many more patients might come to the institution if the process were more patient friendly?) Who will receive the value (faculty members, referring physicians, the institution, other services, patients, etc.)?
Market Analysis
The Market Analysis may tie into the introductory remarks concerning the position/status of the unit in the world of pediatric critical care. This section contains an overview of the local market so that the reader understands which other institutions are also attempting to provide the same or similar services to patients in the general area. An assessment of the current market share for a particular service should be included and can usually be obtained from the hospital's marketing, planning, or finance office. Analysis of population trends and any epidemiologic data that will help to support the request should be included in this section. For example, if the proposal is to develop a specialized trauma response team within the hospital, the plan must provide narrative and supporting data on the numbers of children of various ages who have been involved in trauma. Is the number increasing? Are the types of trauma changing so that a different subset of individuals must be available to care for the patients? Has the time of day or time of year in which trauma victims are admitted to the institution changed? Are other nearby hospitals decreasing their ability to care for the same patient population?
The plan must identify why this unit or division is the appropriate group to receive the support to develop the service being proposed. For a sedation team, why PICU and not anesthesia? For trauma, how will this service incorporate surgical members?

Competitive Analysis
The Competitive Analysis section identifies any direct and indirect competitors, both external (other hospitals) and internal (other services or individuals). How difficult or easy will it be to accomplish the stated goals? How will potential difficulties be overcome? It is useful to clearly identify these obstacles, in that it demonstrates a complete knowledge of the competitive environment and should provide some assurances to the reader that the author has considered methods to overcome the most significant competitive barriers to success. Approaches to overcoming potential barriers are developed in the business strategy section.
Business Strategy
The Business Strategy section contains the description of how the plan will be achieved. It describes how the group will overcome the competitive forces identified in the preceding section. It may include such elements as a marketing plan—how to reach referring physicians, referring hospitals, primary care clinicians, or patients—the volume of services anticipated over a period of time, how the provision of the new service will foster long-term growth for the unit, and similar issues. It will explain how this unit will be differentiated from all other units and why it will become the unit of choice for this particular service. If the unit is not in a heavily competitive environment externally, the business strategy must identify what the benefit will be to the unit's further success. It must also identify why the PICU should receive the resources when other departments or units are simultaneously requesting support for something that they consider equally as important.
Financial Plan
The financial plan will be scrutinized by the administrative staff and must be compiled in a professional fashion, although it is not intended to meet formal accounting standards. It is useful to obtain assistance in composing this section. In short, the financial plan should identify the proposed revenues and costs associated with the program described in the plan. In a hospital setting, the identification of revenues may not always be straightforward, and one must look at all revenues related to the patient population when appropriate. For example, if the leader were proposing to hire a pediatric intensivist who was also a neurologist, revenues that the hospital would derive from additional electroencephalograms and neurologic imaging might be included, even though those revenues might not normally be attributed to the PICU. Similarly, in identifying costs, care must be taken to reflect the total costs that might be attributable to the patient population.
Institutions are particularly interested in the “marginal” costs and revenues associated with a new program. The term marginal can be loosely defined as describing the cost or revenue associated with the next patient. Marginal costs are distinguished from fixed costs, such as the cost of electricity and other things that would be spent even if the additional patient were not there. For example, the cost of drugs used to treat a particular patient is a marginal cost. The costs of nursing care and the costs of other staff can be difficult to assign as marginal or fixed. If another nurse is needed on a shift because of a particular patient, the cost of the nurse is a marginal cost. If the nurse was already there, being paid a full salary even without the patient, then the nurse's salary for that day is fixed. As noted in the earlier section on productivity, decreasing the length of stay for a patient because of a new program will, in essence, decrease marginal costs and potentially result in a net positive financial balance for the institution.
Justifying projects that will have a net negative financial impact is clearly more difficult than if the project will potentially provide a significant new source of revenue or save a significant percentage of current costs. Even if the financial plan indicates a negative impact, however, the proposal may still be supportable if it meets a significant enough need or can yield a significant improvement in quality. It is necessary to acknowledge the negative financial impact in these situations and to identify how the financial burden to the institution will be lessened over time. For example, a proposal to hire enough additional pediatric intensivists to allow the unit to have 24-hr, on-site intensivist coverage 7 days per week might not in itself yield a financial benefit to the institution. However, if the patient population requires this level of attention, the enhanced physician services will improve patient safety and outcomes, in addition to improving night-time teaching and supervision of residents and fellows. These improvements may provide adequate rationale to allow the additional hires, despite the increase in marginal cost.
Operations Plan
In the Operations Plan, the need for additional staff, space, equipment, and similar items is identified. What are the optimal conditions to enable the stated goals to be met? If the entire package cannot be funded, what are the minimal requirements necessary? Sometimes providing the reader the ability to partially fund the request will mean the difference between receiving a portion of what was requested and receiving nothing. It can therefore be useful to make the various operations of the plan contingent on various levels of funding, being clear about what the expected outcomes at each level will be.
The reader also must be confident that any resources provided to the project will be well spent. Therefore, this section should also identify how the project will be implemented: Who will be responsible for project oversight? What milestones will be tracked? When will the leader know if something is not going according to plan, and what will be done about it? A timeline of activities and expected outcomes is helpful in this section. Last, quality management and patient safety issues should be discussed as part of the operations and implementation plan.
The summary section should not repeat the contents of the Executive Summary, but rather should be more of a concluding statement that succinctly integrates the initial vision with the proposed outcome, leaving out most of what is between. It should be no longer than one paragraph and should end on a positive note, reiterating what the proposal will accomplish, for whom, and in what manner.
Business Education for Pediatric Intensivists
Many educational options exist for pediatric intensivists who wish to learn more about business. The choices are as wide

ranging as the needs of the individuals seeking information. They range from 1-day Practice Management courses sponsored by the American Academy of Pediatrics' ( section on Pediatric Critical Care, to Internet-based or live Master's of Business Administration programs, to a variety of courses and graduate degrees available through the American College of Physician Executives ( Additional sources for information and training are listed in Chapter 4.
A Master's of Business Administration or Master's in Medical Management may be most relevant to intensivists who are interested in hospital administration. According to the American College of Physician Executives, hospital physician medical directors and chief executive officers with graduate degrees earn more than those without graduate degrees.
Conclusions and Future Directions
Historically, financial savvy has not been a prerequisite for achievement in academic medicine. Many teaching institutions now require a more rigorous level of financial accountability from their faculty (9,28). It is not uncommon for academic practices to reward clinical productivity with increased income or the opportunity to engage in discretionary spending. In this era of fiscal responsibility, the ability to prospectively model and retrospectively analyze the impact of new codes or billing practices is a necessity for physician leaders. The ability of critical care division leaders to appropriately recruit, mentor, and retain expensive faculty is equally important. Knowing how to obtain the resources necessary to start new programs or develop new services is crucially important. Designers of fellowship programs may wish to include practice management topics in their program curricula.
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