Health Information Management

Q&A: Why did the auditor disallow our order?

APCs Insider, August 30, 2013

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Q: Our cardiology department provides Holter monitor testing. The patients come with an order; we discuss the process, hook up the monitor, and provide them instructions on documenting in the patient log. They return after 24 hours and we unhook the monitor. We also scan the test data and send it to the physician for reading. The physician dictates a report, sends a copy to our department, and the report is filed in the medical record. Our compliance officer is concerned that we don't have enough documentation to support the technical portion of the service. What are your thoughts?

A: Your compliance officer appears to be correct. Although the physician dictated a report that shows the patient had the monitor and what the monitor recorded, the documentation doesn't support whether the physician or the hospital provided the technical component, instructing the patient on when to document in the log, what to document in the log, what to do if he or she experiences any symptoms, when to return the monitor, etc. You should also document the connection and disconnection of the monitor as well as the patient education regarding the log.

Editor’s note: Andrea Clark, RHIA, CCS, CPCH, chairman, CEO, and founder of Health Revenue Assurance Associates, Inc., in Plantation, Fla., answered this question.



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