Hectic ERs present audit challenges, compliance risks
Strategies for Health Care Compliance, December 1, 2008
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The emergency room (ER) is among the most frantic and fast-paced areas in the hospital. Doctors and nurses are under intense pressure to make split-second, life-saving decisions. Not surprisingly, compliance is usually the last thing on their minds, which is exactly why auditing ER visits is so important.
As in many areas of healthcare reimbursement, detailed documentation is necessary for coders and billers to submit correct claims for ER visits.
Clinicians in inpatient clinics usually create thorough records, including physician documentation, nurses’ progress notes, and pharmacy memos. The time crunch in the ER makes this less feasible, says Keith Siddel, MBA, PhD (c), partner at HRM in Creede, CO. “It’s a much smaller record, where everything is jammed together. That tends to make it very difficult to capture everything,” Siddel says.
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