Tip: Cover all your bases in the ER
Compliance Monitor, November 5, 2008
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When auditing emergency room (ER) visits, a thorough examination of the records and claims is just as important as detailed documentation of what happened during a patient’s visit.
Be sure to:
- Check the physician’s documentation sheet and the nurse’s order and treatment form. Are they compatible?
- Look at the triage notes. How severe was the patient’s condition when he or she came to the ER?
- Find out how ER staff members discharged the patient. Did they send the patient home or to a different facility? Make sure the coder coded this correctly.
- Dressing changes. Make sure the physician documents whether he or she used sutures and how the wound was cleaned.
- Splints. Different splints have different codes. Make sure coders capture the correct type of splint.
- Start and stop times for infusions or IV fluids. If the physician does not document these times, the hospital cannot charge for the services.
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