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* Hotline pros and cons
* Are we required to bill for every patient encounter?
* Pay-per-view article: Beyond the basics: Auditing E/M coding and documentation

Compliance Monitor, May 19, 2003

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Hotline pros and cons

Q: Can you give us some general suggestions about setting up a compliance hotline? Specifically, could you give us some insight into the pros and cons of using an outside company to provide the service vs. an internal group that answers these calls?

A: If your company has the resources to do so, you can choose an outside company to answer hotline calls, but many organizations do it internally. There are advantages to using an external company, including

• a greater appearance of anonymity and objectivity
• better tracking mechanisms
• 24/7 coverage
• the availability of expert interviewers who are trained to elicit all necessary information from the callers

The main disadvantage is the cost, although if you use staff to field calls for an internal hotline, rather than using a recorded voice mail system, that's a considerable expense as well.

Whichever method you choose, make sure you publicize the hotline and its purpose throughout the organization. Mention it in newsletters, training, staff meetings, and on bulletin boards. Make sure you publicize the number. Studies have shown that you should get approximately one call per 1,000 employees per month. If your call volume is lower than that, you probably haven't publicized the hotline well enough. Most calls will concern employee-relations issues that are more appropriate for your human resources department than the compliance department. Make sure you decide in advance how you will address these and whether you'll pass them on to human resources. And make sure there is a mechanism for the callers to make a return call and receive feedback anonymously. You can do this by assigning a code or password for them to use.

This question was answered by Stuart Showalter, JD, MFS, director of compliance for Orlando Regional Healthcare System.

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Pay-Per-View article: Beyond the basics: Auditing E/M coding and documentation

If you're looking for a big return from your audit resource investment, consider auditing physician documentation of evaluation and management (E/M) services.

Although organizations use most audits to identify and correct billing and coding inaccuracies, medical record documentation audits go one better: They ensure compliance with state and local regulations, says Ruthann Russo, JD, MPH, RHIT, founder and chief executive officer of HP3, a consulting firm in Bethlehem, PA. This audit also helps to identify missed billing opportunities and assess provider documentation...

Go to "Beyond the basics: Auditing E/M coding and documentation" for the rest of this article. The cost is $10. Subscribers to the online version of Health Care Auditing Strategies have free access to this article. Subscribers to the print edition can find it in their May issues.

A $30 steal!

You can read this article—and much more—in the May issue of Health Care Auditing Strategies. Your cost: Four stories for only $30! You'll learn how to look for holes in your salary process with payroll audits, and how to assess your organization's risks during construction. Choose between a PDF or HTML version for just $30. Online subscribers have free access to this issue. Print newsletter subscribers can find it in their mailboxes.

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Are we required to bill for every patient encounter?

Are we required to bill Medicare for every patient encounter, even when the encounter is medically necessary, but does not require the level of service or standard of care we usually provide? An example: a nurse anesthetist monitors a patient for a podiatry procedure, when an operating room nurse usually handles this.

A: Medicare does not want to be billed for services that are not medically necessary. If an operating room nurse is normally the person to monitor the patient, you would need to have documentation to support why a nurse anesthetist's services were required. If there is no documentation in the record to justify the medical necessity, then you should not bill this.

You need to question why a nurse anesthetist was chosen in this case instead of an operating room nurse. Did this patient have some sort of increased medical risk? If so, that would probably be considered medically necessary, depending on your fiscal intermediary or carrier's guidelines. Did you use the nurse anesthetist because of a staffing shortage, or for educational purposes? If you made the decision for these reasons, you would not likely meet medical necessity guidelines.

This question was answered by Marianne Labahn, RN, BSN, MS, manager of special services for ibex Healthdata Systems, Inc.

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