Tip of the week: Prevent ED revenue loss by educating or retraining your coding and clinical staff
HIM Connection, January 15, 2008
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Medical professionals can identify with the importance of meticulousness, consistency, and accuracy. For physicians and nurses, these words are a mantra for saving lives. Coders understand that these concepts are necessary to ensure accurate coding and compliant reimbursement.
William Malm, ND, RN, practice director of revenue cycle management consulting for HCPro, Inc, located in Marblehead, MA, and Glenn Krauss, RHIA, CCS, CCS-P, CPUR, an independent consultant in Maryville, TN, spoke about these concepts during a recent HCPro audio conference, "Procedure Coding: A team approach to compliant coding and documentation."
Malm and Krauss gave advice about how emergency department (ED) nurses and physicians can correctly capture necessary information in a hectic environment, and thus ensure correct code assignment and full, accurate reimbursement. Malm suggested that HIM/coding professionals do the following to rectify their nurses' lack of documentation:
- Explain to nurses that they should document certain conditions upon arrival, (e.g., the size, width, location, and number of lacerations.) This sets up the framework that their discharge summary and documentation should follow throughout the ED encounter.
- Assist nursing staff members with constructing user-friendly documentation templates.
- Ensure that nurses document each step of the natural flow of patient care within an ED encounter.
- Provide concrete examples of correct documentation versus incomplete documentation.
- Train nurses in groups rather than individually so that no one feels singled out.
- Implement safeguards before the documentation process is complete. For example, in order to catch documentation errors, charge nurses should review records for completeness and accuracy before completing and turning them in to be coded by HIM staff members. This type of real-time feedback is essential.
Editor's note: This tip is adapted from an November 2007 article in Briefings on APCs. For more information, click here.
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