Corporate Compliance

Tip: Cover all your bases in the ER

Compliance Monitor, November 5, 2008

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.
There are certain risk areas auditors should watch for in the ER, including:
  • 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.
This tip was adapted from the article “Hectic ERs present audit challenges, compliance risks,” featured in the October 2008 issue of the HCPro newsletter Healthcare Auditing Strategies. For more information about this newsletter visit the HCMarketplace. 

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