Documentation: Clearing Up the Role of Compliance

Issue Number: 
Volume 2 Issue 2 - Spring 2008
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 Under An EMR System

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. 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 compliance, 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, 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 completeness 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. 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 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 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 accurate, 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. n 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, or via phone at (713) 301-5707.