Today's Wound Clinic - Spring 2008 - (Page 20)

coverstory ness and accuracy of the electronic records compared to paper systems assessed by expert coders.The electronic medical record incorporated clinical structured terminology, American Medical Association CPT codes, and used clinical algorithms that directed physician documentation of the key clinical elements (in other words, it was a Level 4 EMR). What is more important, the electronic records could be easily surveyed for consistency, something not true of the paper templates. percentage of records can be assessed. Some standard system must be put in place to perform this function consistently, and if possible, randomly. To ensure compliance with a paper medical record, utilizing a template, a system for assessing the accuracy of documentation must be developed and maintained. The schedule must be compared to the charge sheets, to ensure that all patients have appropriate paperwork for billing. The charges entered into the system must be compared to the paperwork turned in by the clinical staff. And lastly, the charges that were rate, there should be a check and balance system with the hospital revenue integrity department, or coders. A minimum of a 10% per month audit of the wound care center medical records should take place to ensure the accuracy of the billing and documentation. This is a very time consuming process. An individual patient record can take up to an hour to audit, depending on the complexity of the patient, and the skill of the auditor. The audit results must then be managed and analyzed. If the results were less than stellar, a performance improvement plan must be developed and implemented, and the audit percentage increased to 100% until appropriate results are obtained. Through utilizing an integrated EMR, the burden of assessing compliance is lessened dramatically. Clinical staff perform their documentation, and it is this documentation, which automatically determines the level of service provided.This linkage between documentation and billed level of service assures compliance in 100% of clinical records. No separate audit process is necessary. This is the most efficient and comprehensive compliance tool, but also requires the most commitment to implement. Moira Hayes, MHA, RRT, CHT is the CEO of Innovations Healthcare Consulting, Inc. of Houston,Tex. She can be reached with questions or consultations via her email address at moira.hayes@sbcglobal.net, or via phone at (713) 301-5707. COMPLIANCE CONSIDERATIONS Accurate and compliant documentation is the cornerstone of both clinical care and fiscal viability. If paper charts continue to be the standard at a facility, then a compliance program must be put in place to assess that certain types of documentation are consistently available in the record (photographs, measurements, and so on), and that billed level of service reflects the documentation. This will necessitate staff member time, and likely the involvement of a professional coder. Furthermore, staff will have to ensure that facility documentation and physician documentation agree with each other in key areas such as debridement. If templates are used to facilitate clinic billing (and for the most part, templates are still used in the context of a paper based medical record), compliance must not only include ensuring that source documentation reflects what is checked in the template, but that the point system used is likely to result in a normal or bell shaped distribution of charges. In other words, a point distribution cannot be intentionally selected to skew points to higher levels of service.1 A template system will likely still require staff member time to ensure compliance, cross checking activities marked on the template with those available in the chart. With paper based systems, it is not feasible to ensure compliance in 100% of medical records. Only some 20 Spring 2008 Today’s Wound Clinic “ACCURATE AND COMPLIANT DOCUMENTATION IS THE CORNERSTONE OF BOTH CLINICAL CARE AND FISCAL VIABILITY.” entered must be compared to the medical record for accuracy after the physician dictation has returned to the center. Each chart must be reviewed for accuracy by a designated and trained individual in the center. Any changes or discrepancies must be noted, and the charges adjusted to reflect only those charges that are appropriate.This process is much more difficult than it sounds, given the numerous requirements for procedural documentation, evaluation and management documentation, advanced therapy modalities such as hyperbaric oxygen therapy, negative pressure therapy, dressing selection, and so on.There are mitigating factors in almost every medical record that create innumerable scenarios for billing errors. After the wound care department has determined that the charges are accu- REFERENCES 1. Johnson, KM.The massive medical coder shortage. Revenue Cycle Strategist. 2008;5(2):1–3. 2. Fife CE, Walker D, Farrow W, Otto G. Wound center facility billing: A retrospective analysis of time, wound size, and acuity scoring for determining facility level of service: Ostomy Wound Manage. 2007;53(1):34–44. 3. King MS, Sharp L, Lipsky MS.Accuracy of CPT evaluation and management coding by family physicians. J Am Board Fam Pract. 2001;14(3):184–192. 4. Silfen E., Documentation and coding of ED patient encounters: an evaluation of the accuracy of an electronic medical record. Am J Emerg Med, 2006;24(6):664–678

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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