The usage of Observation units (OUs) has been essential in emergency departments (EDs) due to the increase in benefits it has portrayed. Centers for Medicare and Medicaid Services (CMS) policies incentivize documentation for patient disposition regarding the patient's time spent in the OUs. The study conducted allows for the investigation of whether PAs within the Long Island Jewish Medical Center ED's OU document times greater than 31 minutes leading to a term known as upcoding or ending times in 0 or 5, for their preference. Investigation of this topic will allow the determination of if PAs are trying to have an increase in reimbursement for times greater than 31 minutes. Between June and July 2024, documentation proceedings for 102 patients dispositioned from the OU were conducted. We evaluated the documented times and analyzed the influence of upcoding from seven emergency department physician assistants (PAs). The time documented did not have below 31 minutes. Nearly 50% of reported times ended in digital numbers 0 or 5. Approximately 50% of times were recorded at 31, 32, 33 minutes. These results concluded that PAs may be adjusting documentation times to meet CMS's reimbursement incentives, which can lead to inaccurate time reporting and an increase in upcoding leading to reimbursement. The documentation of times near greater than 31 minutes and ending in 0 or 5 suggests that reimbursement incentives can lead to the influence of altering patients' time in the ED's observation unit. Further research is needed to confirm these findings and analyze the impact of CMS policy changes on documentation in healthcare.

The authors have declared no competing interest.

This study did not receive any funding.

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

Ethics committee/IRB of Northwell Health Institutional Review Board's (IRB's) Human Research Protection Program (HSRD24-0133), waived ethical approval for this work.

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Yes

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

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I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

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The data is available upon request from the corresponding author, Dr. Richman. The data utilized for this research were provided by Dr. Richman, who works in the Emergency Department at LIJ, through his portal access.