Documentation: Clearing up the Role of Compliance

May 12, 2008 | Leave a Comment

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

Posted by jcalder | Filed Under Cover Story, Spring 2008 

The Clinician’s Role in Compression

March 17, 2008 | Leave a Comment

Susan Gallagher Camden, RN, MSN, WOCN, PhD
Tere Sigler, PT, CWS, CLT

Lymphedema, a disorder of the lymphatic system, affects at least 3 million Americans.1 The lymphatic system plays a role in both immune function and circulation. The system is comprised of lymphatic vessels located just under the skin and lymph nodes in areas around the neck, axilla, and groin. As the vessels transport fluid away from the tissues, waste products, bacteria, and large protein molecules are collected. The fluid is carried to the lymph nodes where the water products are degraded and eliminated, while the remaining protein-rich fluid is transported to the heart and back into circulation.2
When the normal lymphatic channels are disrupted, abnormal amounts of protein-rich lymphatic fluid collects in the interstitial tissue and causes swelling, most often in the arm and/or legs, and occasionally in other parts of the body. When the disruption becomes profound, the volume of lymphatic fluid exceeds the lymphatic transport capacity, leading to lymphedema.
Primary lymphedema is caused by connatal malformations of the lymphatic system, such as missing or impaired lymphatic vessels. This can affect any or all parts of the body but is usually seen in the legs. Secondary lymphedema, sometimes referred to as acquired lymphedema, occurs when lymphatic vessels are damaged or lymph nodes are removed. The lymphatic vessels can become damaged as a result of trauma, surgery, radiation, severe chronic venous insufficiency, morbid obesity, or infection. Without appropriate intervention, the protein-rich fluid increases the size and number of the tissue channels. This contributes to a reduction in the oxygen availability in the transport system, which interferes with wound healing and provides a culture medium for bacteria. This increased bacterial load can result in lymphangitis. When lymphedema continues unchecked, the protein-rich fluid continues to accumulate, swelling increases, and tissue becomes fibrotic. Untreated lymphedema can lead to a decrease or loss of limb function, skin breakdown, or chronic infections.

For a preview of this article in the TWC digital edition visit:
The Clinician’s Role In Compression
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Posted by jcalder | Filed Under Cover Story, Winter 2008