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The Business of Neurocritical Care: Practice Models and Models of Documentation

By Currents Editor posted 09-07-2021 09:42


Ryan Hakimi, DO, MS, NVS, RPNI, CPB, FNCS

This series will be a running feature highlighting billing, coding, practice management, and other business aspects of neurocritical care.

When assembling and organizing a Neuro ICU team, one must begin with the end in mind. It is important to note that each organization defines financial success of the Neuro ICU differently. To meet the organization’s marker of success, one must first determine how it is defined by the organization and then adapt staffing and documentation to best meet these goals while considering the case mix and payer mix. Here we describe some common models with pros and cons for each:


wRVU = work relative value unit

Provider = Attending physicians + APPs

Compensation = salary + bonus + malpractice insurance  + total cost of benefits

E&M = Evaluation and Management

Total provider wRVU

Pro: Chronic static patients are seen by APPs (sometime called non-teaching service). The attending physician (with or without house staff) only sees the complex critical care patients allowing for a higher total number of patients to be seen by the team daily.

Con: There is a potential for job dissatisfaction for the APPs who may perceive that they are only writing notes without making substantive medical decisions. In addition, this model requires more experienced APPs who can function essentially independently and who may be more difficult to recruit.

Physician wRVU (attending physician wRVU only)

Pro: In this team-based model, every patient is seen by the attending physician (with or without house staff) who bills for his or her critical care work as well as the APP’s work (and house staff’s work) on E & M patients.

Con: There is a limit on the number of billable critical care patients one attending physician can see thereby limiting growth of the program. The APP may feel that his/her documentation is not valued as it is not being used for billing purposes on critical care patients.

Total collections/total provider compensation (where total provider compensation = attending physician compensation + APP compensation)

Pro: Since routine post-operative care in not billable and is bundled into the global fee assigned to the surgeon of record, anesthesia services, and the hospital, the Neuro ICU APP can see these patients by him/herself. This allows for the highest total number of patients to be seen daily as the attending physician can focus their time (with or without house staff) on billable critical care and E&M patients only.  

Con: This model is best for Neuro ICUs that have a large number of routine post-op patients. It can result in APPs being assigned to care for static chronic patients (sometime called non-teaching service) or “normal” patients, which can impact the APP’s job satisfaction and growth. The Neuro ICU providers may also feel that they have no control over the payer mix of the patients they care for. Furthermore, this model requires more experienced APPs who can function essentially independently and who may be more difficult to recruit.

Total wRVU/total provider compensation

Pro: Fewer physicians are needed per APP, thereby the cost to the organization is much lower.

Con: All providers will be expected to see as many billable patients as possible per day leading to an increased risk of burnout.

Total patient billing/total provider compensation

Pro: The billed amount is the same for all patients with the same care which eliminates the concern over payer mix and collections.

Con: There may be an implied incentive for providers to overbill, especially if bonuses are tied to billing. Total patient billing is artificially inflated and not in line with modern hospital reimbursement which is typically based on value-based purchasing.

There are several other models, but the above represent the most common ones in the United States.

Given that there is significant variability in organizational financial goals, case mix, payer mix, the extent of house staff support, the extent of APP support, and unit size, there is not one staffing or documentation model that can serve the needs of every organization. It is important that Neuro ICU physician leaders recognize this and not necessarily try to emulate what they experienced during their training as it may not be applicable in their current local practice environment. Furthermore, when recruiting new physician and APP providers, it is incumbent on the Neuro ICU leaders to discuss the practice model and documentation model, as clear representation of the local practice environment (and subsequently managing provider expectations) is the single most controllable determinant of recruiting and maintaining a successful Neuro ICU team.

Further elaboration on the impact of documentation elements on provider billing and determination of hospital mortality index and resultant hospital star rating will be discussed in a future article.


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