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Improved nursing documentation also can reduce legal concerns
If the nursing documentation in your emergency department (ED) is lacking key information, your facility may not be getting all the reimbursement it deserves. More ominously, inadequate nursing documentation can open the door for costly legal action down the road.
Candace E. Shaeffer, RN, MBA, RHIA, vice president of coding/quality management at Lynx Medical Systems in Bellevue, WA, says that appropriate nursing documentation is especially important when it comes to the Centers for Medicare & Medicaid Services’ (CMS) outpatient prospective payment system (OPPS), which includes significant increases in payment for some procedures. "Capture of these charges depends on sufficient documentation," she notes.
"You can look at documentation from two perspectives," Shaeffer says. "They should be blended into one. There’s clinical documentation — what’s good for medical/legal aspects of delivering care for the patient; what’s required for that? And what’s required for coding? They’re usually just a little bit different, although they shouldn’t be."
Currently, there is no national guideline to specify what documentation is needed for correct coding or for reimbursement, she adds. "CMS has told each facility to develop its own system."
In 2000, when ambulatory payment classifications were introduced as part of the OPPS, CMS in its final rule said facilities were expected to develop a system that met certain criteria that would assure the facility was in compliance with OPPS guidelines. Requirements include:
"Beginning at that time," Shaeffer says, "everybody scrambled to try to put a charging mechanism in place so they could capture all the resources that were expended during an ED visit. We were directed to use the CPT, which is applicable to physicians. And the descriptors for the various codes — 99281 through 99285 — weren’t clearly applicable to the facility side. So you’ve got some very interesting systems out there."
Because every facility currently has its own system, "adequate documentation is going to be predicated on whatever system a site chooses. For instance, if a site has developed a point system, and part of the point system is dependent on the mode of arrival [i.e., a patient who arrives by ambulance is assigned more points than someone who walked in the door] then, for that site, it’s going to be critical that they document the mode of arrival."
Also, facilities must ensure that whatever system they’ve developed meets accreditation requirements from their state and from the Joint Commission on Accreditation of Healthcare Organizations, she says.
Currently, an expert panel is putting together recommendations to CMS about a uniform model for facility coding, which could be in place as soon as 2004. Although it’s unclear exactly what that model will look like, it could resemble in some respects the system developed by the American College of Emergency Physicians (ACEP) and backed by the American Hospital Association and the American Health Information Management Association.
"I believe that they’re still looking at that model and trying to tweak it," Shaeffer says. "CMS’ big concern was that there were separately billable procedures included in the ACEP model, so of course you have the concern of double-billing. If you’re charging for a procedure separately — say, an IV infusion, and you’re also including it in a category of interventions that would be used to evaluate and calculate the visit level, then you’re essentially using it in a double-billing mode. They have to go through and eliminate that double-billing issue."
In any case, ED professionals can’t simply wait for CMS to decide on a final model before taking steps to improve their documentation. Whatever system you have in place at the moment — whether it’s a point or acuity system or something else — chances are there are things you could be doing with your documentation to more fully optimize reimbursement and minimize legal liability.
"The overarching policy would be to thoroughly document all of the services provided, and make sure the nurses know about those procedures that are separately billable so they can for sure document all of them if they have some type of template or form," Shaeffer says.
Patti Muller-Smith, RN, EDd, a consultant with Administrative Consulting Service Inc. in Shawnee, OK, says that the most common reason for inadequate documentation in the ED is the fast-paced environment. While ED nurses may commonly be documenting what they do, "they’re not necessarily supporting the why of what they’re doing," Muller-Smith says. "If you go back and look at a document — perform a chart review — basically what it should do is paint an absolute picture or provide a road map for the course of action that the nurse took at each point in the treatment of the patient. Sometimes it’s not clear why they chose to do something, [perhaps] because the changing patient status wasn’t documented, the fact that they notified a physician was not documented, and those types of things. Now, they’ve done them; it just was not documented."
Certainly nursing documentation must be thorough to make sure all appropriate charges are captured. Inadequate documentation also can cause your ED to lose out on the appropriate visit level. Shaeffer explains that if you are using a point system to calculate the facility visit level, resource points are added to arrive at the total number of points, which is compared with the minimum point requirement for each visit level. Additional resource points are added for specific tasks or services, such as a visit from social services.
Therefore, if a service was performed but not documented, a lower level of service would have to be assigned, she says. For example, if additional points are earned when the patient arrives by advanced life support transport, then you must document this means of arrival. "Likewise, if additional points are earned when a patient is placed in restraints, this should be documented," Shaeffer says.
To encourage thorough nursing documentation for whatever system your ED is using, it’s necessary to establish a set of documentation guidelines that incorporate requirements from the state and the Joint Commission and recommendations from other groups. For example, "AHIMA [American Health Information Management Association] recommends certain documentation be present for quality," Shaeffer says. She adds that facilities "should take a look at all that information and make sure that they have an internal policy that specifies the things that need to be documented. And of course you have to have some guidelines before you can audit. You’d audit based on the standards that you’ve established."
Whatever methods of documentation and coding are implemented, the records should be audited for documentation as well as coding quality, Shaeffer notes. That means developing an audit checklist. "They would take whatever coding system they had and determine what drives the payment," she says. Is it a point system? If it is, what criteria are on it? "Develop a checklist with each of those points on there and have them take a look at their actual documentation audit and give the nurses feedback. Let the nurse manager give them a report about how much money was left on the table."
For example, a focused audit of injections could examine documentation to find out how many injections were documented appropriately so as to allow charging. "If the route [of administration] wasn’t there and they couldn’t charge for it, then quantify the loss in dollars, and that will really impress the nurses — to let them know, Hey, we could have billed X dollars; but instead, we only billed Y dollars for the month of March.’ And if you annualize that, it’s probably a huge chunk of change," Shaeffer explains.
She also recommends that whoever’s doing the coding examine the physician documentation in addition to the nursing documentation. "It’s a good idea that the coder look at the physician documentation as well to use it as a kind of cross-reference to make sure that they’ve completely coded or charged for all of the specific procedures that are separately billable and that were done during the encounter," Shaeffer says.
An example of this is the case of lacerations. "You can assign lacerations on the facility side, but often times [the nurse] may not clearly say that there was a laceration repair done." All of the laceration codes define specific body area and lengths, Shaeffer notes. "And if the length isn’t there, you can’t code it. So a coder would either have to go back to the nurse or go back to the physician to find out what the length is. And nurses rarely if ever would document that."
Finally, Muller-Smith notes that, in addition to issues of reimbursement and liability, thorough documentation by nurses helps "demonstrate the skill and competence that you bring to that particular patient that cannot be provided by another provider."