Today's Wound Clinic - Spring 2008 - (Page 18)

coverstory focused audit of billed charges, but it is not a practical method to determine the billed level of service on a day-today basis for billing purposes. In day-to-day practice, the most common method for determining billed level of service is simply to have the provider estimate the work they have provided, based on their personal assessment of the subsequent clinical documentation. The problems associated with this option in the wound center setting have been described previously. Dr. Fife and colleagues demonstrated that allowing facility staff to estimate the level of service they provided (using time as a metric) consistently resulted in an over-estimation of actual services when compared with specific measures of staff work.2 Physicians may not be any better than nursing staff when it comes to using their own documentation guidelines. A recent study compared the coding accuracy of 600 family practice doctors with professional coders.3 Family physicians agreed with the experts that only 17% of the time for new patient visits, the predominant error being over-coding by physicians. Thus, data suggest that when either physicians or nursing staff estimate their level of service after seeing a new patient, they will over code. The over-coding is probably due to the difference between the work one perceives one has provided, and the necessary documentation to justify this work. Even though a higher level of care might have actually been provided, if the documentation does not support the level of service, which was billed, it is still considered over-coding. Facility billing is an additional alternative to using a template to track specific work related tasks. The concept is to create a paper document listing a variety of work tasks each of which are given a point value. The total point score then tracks to level of service.The template is not really part of the medical record. The work tasks performed must still be documented somewhere in the chart.While templates can be a useful tool, rather than ensuring compli18 Spring 2008 Today’s Wound Clinic ance, templates can actually create compliance problems. There is no feedback system to ensure that only those activities actually performed are marked on the template, unless a dedicated individual is tasked with abstracting the chart (back to option number one). Thus, templates are an example of an open loop system, which can actually create compliance issues. At this time, templates might be the most commonly used option for calculating facility work in hospital based outpatient wound centers. In the absence of a specific Medicare ruling on outpatient billing, “EVEN THOUGH A HIGHER LEVEL OF CARE MIGHT HAVE ACTUALLY BEEN PROVIDED, IF THE DOCUMENTATION DOES NOT SUPPORT THE LEVEL OF SERVICE, WHICH WAS BILLED, IT IS STILL CONSIDERED OVER-CODING.” there are significant challenges in creating the template, ensuring that the point distribution will yield a normal distribution of charges and not skew charges to the right (ie, toward higher levels of service), and implementing the template consistently when complex work tasks are involved. A third option is to use an EMR to ensure a direct correlation between documentation and billed level of service. In this option, the computer functions like a coder and abstracts the documentation within the electronic medical record to calculate the level of service. This type of calculation cannot be performed with electronic documentation systems, which use text fields. The data fields require a significant amount of backend programming to make this possible. The EMRs, which can perform these calculations, are referred to as Level 4 EMRs.There might be electronic systems, which the physician or nurse selects the level of service provided by clicking a check box, but such a system is really no different than using a paper template. Only if the calculations are internal to the programming does the system qualify as an electronic medical record. This is a key feature to understand when you are selecting a program for your facility. A Level 4 EMR, which automates billing, is ideal from a compliance standpoint because compliance is also automated. While there is no downside from the standpoint of compliance, clinicians and other healthcare professionals may be wary of having a true electronic medical record. They may be uncomfortable navigating through computer screens rather than flipping through chart tabs. Medial record’s policies and procedures may need to be altered to accommodate a paperless system. Coders and auditors will need training to facilitate hospital revenue cycle management. However, it has been this author’s experience that implementing an electronic medical record system for wound care is well worth the effort. Cheri Conerly, director of revenue integrity, Hospital Partners of America, is a proponent of electronic medical records for the wound care service lines. “Electronic medical records facilitate the coding, nursing, support staff, and physician documentation for each patient,” Conerly says. “Everything ties, and only appropriate charges are entered. The audit process is much easier and faster.” Electronic medical record systems have been used in settings other than wound care to facilitate documentation accuracy. A unique study evaluated emergency services provided by two hospitals, one using a paper-based, template-driven system and the other a specialty specific electronic medical record.4 There was no statistically significant difference between the complete-

Table of Contents Feed for the Digital Edition of Today's Wound Clinic - Spring 2008

Today's Wound Clinic - Spring 2008 Contents InTroduction InBusiness Documentation: The 30,000-Foot View Documentation: Clearing Up the Role of Compliance InTech InPhotography InFluence InStruction InNews InCentive Ad Index

Today's Wound Clinic - Spring 2008

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