title: The impact of a standardized consultation form for facial trauma on billing and evaluation and management levels.
abstract: BACKGROUND
  Facial trauma is among the most frequent consultations encountered by plastic surgeons. Unfortunately, the reimbursement from these consultations can be low, and qualified plastic surgeons may exclude facial trauma from their practice. An audit of our records found insufficient documentation to justify higher evaluation and management (EM) levels of service resulting in lower reimbursement. Utilizing a standardized consultation form can improve documentation resulting in higher billing and EM levels.
  
  
  METHODS
  A facial trauma consultation form was developed in conjunction with the billing department. Three plastic surgery residents completed 30 consultations without the aid of the consult form followed by 30 consultations with the aid of the form. The EM levels and billing data for each consultation were obtained from the billing department for analysis. The 2 groups were compared using χ2 analysis and t tests to determine statistical significance.
  
  
  RESULTS
  Using our standardized consultation form, the mean EM level increased from 2.97 to 3.60 (P = 0.002). In addition, the mean billed amount increased from $391 to $501 per consult (P = 0.051) representing a 28% increase in billing.
  
  
  CONCLUSIONS
  In our institution, the development and implementation of a facial trauma consultation form has resulted in more complete documentation and a subsequent increase in EM level and billed services.
authors.affiliation: From the *Division of Plastic Surgery, Albany Medical Center, Albany, NY; and †Certified Plastic Surgery of New York, Latham, NY.
authors.forename: Andre Y
authors.initials: AY
authors.lastname: Levesque
authors.forename: David M
authors.initials: DM
authors.lastname: Tauber
authors.forename: Johnson C
authors.initials: JC
authors.lastname: Lee
authors.forename: Jose R
authors.initials: JR
authors.lastname: Rodriguez-Feliz
authors.forename: Jerome D
authors.initials: JD
authors.lastname: Chao
mesh_terms: D004282:Documentation / Q000191:economics / Q000592:standards*; D005151:Facial Injuries / Q000191:economics / Q000601:surgery*; D006801:Humans; D009518:New York; D012017:Referral and Consultation / Q000191:economics* / Q000458:organization & administration; D012051:Reimbursement Mechanisms; D013518:Surgery, Plastic / Q000191:economics* / Q000458:organization & administration