Documentation: Clearing up the Role of Compliance

May 12, 2008

Ensuring the Charts Match the Care Received

Moira Hayes, MHA, RRT, CHT

Compliance in the US generally means adherence to laws and regulations. Corporate scandals and breakdowns such as the Enron case in 2001 have highlighted the need for stronger compliance regulations for publicly listed companies. In the medical world, focus is on maintaining regulatory compliance in all activities of documentation and coding for billing professional services. The importance of documentation has been emphasized throughout this issue of TWC. With regulatory organizations closely monitoring activities, patient quality of care at stake, and the financial success of a wound center dependent on the quality of documentation, a compliance process is an absolute necessity. How will wound centers ensure what ends up in the chart accurately reflects the care that was provided to the patient, as well as the services that were billed?

Auditing Options
Although physician and facility billing are controlled by separate governmental requirements, there are two overarching principles which apply to documentation compliance:

1) Billed level of service must correlate with the level of service documented in the chart. This is applicable for both the physician and the facility.

2) In some circumstances (ie, surgical excisional debridement), the level of service billed by the physician and the facility must correlate with each other.

Many healthcare organizations have been scrutinizing the documentation and revenue cycle of their outpatient wound care programs. Some organizations have no audit process at all, while others may audit 100% of charts, involving many hours of resources. However, most audit programs fall somewhere in between. Not only must a facility determine the method of audit, but the sample size. Some facilities may choose to perform a random audit of a specific percentage of charts (ie, one chart in 10). Alternatively, all charts might be audited over a specific time frame (eg, 1 month).

Typically, one of the following three methods is used to determine the billed level of service for either the physician or the facility:

1) Abstraction of the paper chart by a trained expert.

2) Allowing the provider to estimate their level of service and select it on the charge master.

3) Using an electronic medical record (EMR) to directly calculate the billed level of service based on documentation.

Abstraction of the chart by a professional coder continues to be the gold standard, particularly in relation to physician level of service. Depending on the training and skill of the coder, this is more than likely the most accurate method of ensuring correct correlation between clinical documentation and billed level of service. Abstraction is the most expensive yet least efficient billing method. Professional coders are also the gold standard for the abstraction of the diagnostic and procedural levels of service provided in a facility. However, there is an almost crippling shortage of qualified medical coders which threatens the revenue cycles of many institutions, as discussed by Kathy M. Johnson in the February issue of the Revenue Cycle Strategist.1 Abstraction of charts might be a reasonable method for performing a focused audit of billed charges, but it is not a practical method to determine the billed level of service on a day-to-day basis for billing purposes.

 

For a look at this complete article in the TWC digital edition visit:
Cover Story

Documentation: Clearing up the Role of Compliance | Filed Under Cover Story, Spring 2008 

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