Documentation:The 30,000-Foot View
May 12, 2008 | Leave a Comment
Caroline Fife, MD, FAAFP, CWS
Documentation is an intrinsic component of every patient encounter. The financial success of a facility depends upon the completeness of the process. The major factor affecting the quality of an organization’s data (and therefore its revenue stream) is the accuracy of documentation. If you are not already convinced of the importance of accuracy in documentation, a study by the Centers for Medicare & Medicaid Services (CMS) found that of all of the improper Medicare benefit payments made during 2001, 43% were due to documentation errors. It is well known that patient quality of care is also related to quality of documentation. Furthermore, documentation is essential to meet the changing demands of regulatory bodies such as the The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), the Office of the Inspector General (OIG), and CMS.
The What and Why of the Medical Record
In the 19th century, the medical record was a sort of personalized lab notebook in which clinicians recorded their observations. In the 21st century, the medical record has many functions, including, serving as a basis for planning and documenting patient care, communicating among numerous health professionals, and protecting the legal interests of the patient and healthcare providers. The medical record may supply information for internal hospital auditing and quality assurance, documenting compliance with governmental regulations, and provide data for medical research. It is also a means of determining the billed revenue for physicians and hospitals. Thus, documentation must validate the medical necessity and appropriateness of the diagnostic and/or therapeutic services provided. What is more interesting about today’s medical records is that they serve as a way of tracking the process of care not just for an individual patient, but for groups of patients in the form of benchmarking and clinical research.
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InWhole
Lack of Documentation May Cause Loss of Dollars
May 12, 2008 | Leave a Comment
Kathleen D. Schaum, MS
E arly in their medical/clinical training, wound care physicians and clinicians learn the caution, if it’s not documented, it’s not done. Few physicians and clinicians, however, realize the enormous financial consequences that the lack of documentation can have on their practices if:
• they perform self-audits and find that their documentation did not support the codes that were billed and the payments they received and/or
•they receive a Medicare audit and find that their lack of documentation resulted in false claim submissions.
In wound care settings a variety of physicians and clinicians practice as a team to achieve excellence. Each member of that team should take personal responsibility for clearly documenting the work they perform. These professionals should not only use the documentation guidelines learned during their medical training, but should also follow the guidelines of the payers who review their claims for medical necessity. Most Medicare contractors provide educational seminars, webinars, online training, educational documents related to documentation, medical policies, and articles that include documentation requirements.
In the middle of 2007, the Office of Inspector General (OIG) released several reports regarding the wound care industry:
• May 2007: Medicare Payments for Surgical Debridement Services in 2004.
•June 2007: Medicare Payments for Negative Pressure Wound Therapy Pumps in 2004.
Unfortunately, both reports found that documentation in the medical records of wound care patients did not adequately support medical necessity of the procedure(s) performed and/or the product(s) ordered. The OIG found Medicare overpaid $64 million for false claims involving surgical excisional debridement and $27 million for false claims involving negative pressure wound therapy pumps and supplies.
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Editor’s Message: On Demand: Bridging the Gap
May 12, 2008 | Leave a Comment
TWC has great potential for expanding and reaching new readers via the Internet while still providing our valued product in print. We don’t believe that the digital edition will replace the print issue. In fact, we suggest that you subscribe to both in order to have our content available on demand, anytime and anywhere you want it.
Our IT team has partnered with Nxtbook Media to give our paying subscribers the added bonus of receiving a digital edition when they subscribe to the print journal. Readers also will have the option of subscribing to the digital edition alone at a discounted rate.
The staff at HMP, invites everyone to a free preview of TWC’s digital edition of the Winter 2008 issue at: http://digital.todayswoundclinic.com/nxtbooks/hmp/twc_2008winter/
Survey Says
TWC is your source for the latest information on wound care clinic operations. Through our Exit Polls, we are actively collecting information on the industry in four separate survey categories. We will analyze this information and with our readers help, we will define the industry. Your participation in these surveys is essential for creating knowledge and standards of practice in management across the wound care industry. All responses are completely confidential and for research purposes only. The Spring survey will cover staff responsibilities. A link to participate in both the Winter and Spring online survey can be found on the home page of TodaysWoundClinic.com, under Exit Polls. Thank you in advance for your participation.
In late April, TWC staff will be attending SAWC (www.sawc.net) in San Diego, Calif. I look forward to meeting many of you for the first time and the opportunity to discuss your needs and goals for the journal and what topics you would like to see covered. Your feedback on the journal is not only wanted and needed but is crucial for the success of the publication. Please email me anytime to share your thoughts.
Sincerely,
Managing Editor
jcalder@hmpcommunications.com
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Editor’s Message
Documenting Your Success
May 12, 2008 | Leave a Comment
There is an ancient Chinese proverb which says, the palest ink is better than the best memory. This issue is about medical documentation. These days, documentation may or may not be done with ink, but there is no question about the importance of providing a record of the care we have provided. The issue of documentation is enormously complex. The topic includes not only how information is to be collected (with paper, electronically or even some mixture of the two), but also how information will be used.
To begin, we will take a 30,000-foot view of documentation, that includes general principles—which must be observed, and the rules that govern physician and facility documentation. Do you know where your medical records are? The answer can be more complex than one might think. In a modern clinic, the medical record, rather than being a collection of paper, might consist of many different types of data that are, stored in several ways. For example, how are the digital photos identified as part of the legal chart?
In fact, wound photography can become an important legal discussion. Val Sullivan will discuss what types of equipment work best for documentation and the litigation process, with nurse legal consultant Mary Bruno.
With regard to data, how do data get into the medical chart? Do you have an audit system to ensure the quality of the data in your charts? Moira Hayes will discuss documentation compliance programs, which are critical to having a successful clinic.
Have you thought about transitioning to an electronic medical record system? We will take a close look at three options for documentation. Dot will discuss how she uses NetHealth’s WoundExpert System, (Pittsburgh, Pa), Caroline will discuss how she uses Intellicure’s Electronic Medical Record, The Woodlands, Texas, and N. Blair Hughes, MHS, PT, CWS will review the option provided by Wound Care Strategies, Inc., Harrisburg, Pa.
In our InBusiness section, Kathy Schaum will discuss how Medicare contractors include documentation guidelines in their Local Coverage Determinations and Articles, using examples from actual wound care related LCDs and Articles.
Would you like to sound like an expert? You will after you read Heidi Mueller’s InFluence section. She will tell what (and when) to copy to your referring physicians, and what to include in progress reports.
You are sure to enjoy our featured wound care center, the O’Connor Wound Care Clinic, and the Q&A with Medical Director Peter Schubart, MD, PhD.
Lastly, don’t miss a preview of our next online survey in Exit Polls. Our
Medical documentation will determine the success of your facility. No topic may be more important to Today’s Wound Clinic. We think this is our best issue yet, and we hope you agree.
Caroline Fife, MD, FAAFP, CWS and Dot Weir, RN, CWON, CWS
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Introduction
