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Book excerpt: Defining clinical documentation and coding standards in the revenue cycle, integrating real-time auditing, part 2

Lamkin_Elizabeth

by Elizabeth Lamkin, MHA, ACHE

by Elizabeth Lamkin, MHA, ACHE

To reinforce formal documentation education provided to physicians and staff, open chart auditing and real-time education is needed. Effective facilities typically have a CDI program staffed with trained professionals to concurrently audit every open chart and query providers to obtain clarifications and additional documentation when needed.

Placing CDI staff on the clinical units to audit chart documentation in real time and personally interact with physicians and other clinical staff, often helps with education effectiveness as well. The CDI specialist can query the physician to explain why the documentation does not meet criteria or does not really tell the story of the patient’s condition.

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Summer reading: Defining documentation and coding standards in the revenue cycle, part 1

Lamkin_Elizabeth

Elizabeth Lamkin, MHA, ACHE

by Elizabeth Lamkin, MHA, ACHE

Accurate clinical documentation is the bedrock of the legal medical record, billing, and coding. It is also the most complex and vulnerable part of revenue cycle because independent providers must document according to intricate and sometimes vague rules. A facility’s revenue cycle plan should define the necessary education on documentation, when and how this education will be delivered, and how compliance with education will be reported.

It is difficult to hold physicians and other medical staff accountable for applying the rules if they are not educated on what the most current rules require. Physician engagement increases if education includes why documentation is so important and why it must be done correctly while the patient is still in the hospital. Physicians normally do not receive formal education or training on documentation to meet regulatory and coding criteria in their training programs or through continuing education; therefore, it is up to the hospital to stay current on regulations and documentation rules and to provide training to physicians.

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News: Study reveals overspending on U.S. billing and insurance paperwork

CMS says new date for ICD-10-CM/PCS implementation set for 2015.

Billing paperwork costs billions

Healthcare organizations spent approximately $471 billion on paperwork related to billing and insurance in 2012, with 80% of that potentially wasted, according to the study “Billing and insurance-related administrative costs in United States’ health care: synthesis of micro-costing evidence,” published in BMC Health Services Research.

Using a standard definition of “billing and insurance-related costs” (BIR), researchers found that physician practices spent approximately $70 billion, hospitals spent roughly $74 billion, and other institutions (e.g., nursing homes, home health care agencies, prescription drug, and medical supply companies) spent approximately $94 billion. Private insurers spent approximately $198 billion on BIR compared to $35 billion spent by government-sponsored health insurance programs.

Adopting a simplified, single-payer insurance system similar to Medicare could save the U.S. approximately $375 billion annually or more than $1 trillion in three years.

Editor’s Note: This article originally published in the HIM-HIPAA Insider.

Three-day payment rules changed

Hospitals clamoring for guidance from CMS about the three-day payment window must now grapple with legislative changes to the requirements that carry significant revenue implications and could potentially affect the national recovery audit contractor (RAC) program.

President Obama on June 25 signed the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010, which contains a section to clarify the three-day payment window, or three-day rule. The three-day rule previously stipulated that hospitals must bill as part of an inpatient stay all diagnostic services provided within three days of admission, as well as all non-diagnostic services related to the inpatient admission.

CMS had previously defined “related” to be an exact diagnosis code match between the inpatient admission and the outpatient therapeutic services. Hospitals had struggled to correctly apply the rule in their billing operations.

“This has been a gray area for a very long time and has caused confusion for both the MACs/FIs and providers,” says Karen Sagen, revenue audit coordinator at Bellin Health in Green Bay, WI.

Such confusion had recently come to the fore on several of CMS’ Hospital and Hospital Quality Open Door Forum conference calls, during which the provider community posed numerous questions regarding the rule. “Clearly over the last couple of months it has come to light that providers were all doing something different, due to the lack of clarification,” she says.

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