Is your documentation lacking key information?

Experts: You may be missing out on reimbursement

Do you realize that the way you document can have a significant impact on the reimbursement your emergency department receives? This is especially true with ambulatory payment classifications, according to Candace E. Shaeffer, RN, MBA, vice president of coding/quality management at Lynx Medical Systems in Bellevue, WA.

Shaeffer reports that many emergency departments (EDs) are missing out on reimbursement because of inadequate nursing documentation. She points to the proposed rule from the Baltimore-based Centers for Medicare & Medicaid Services (CMS) for the outpatient prospective payment system (OPPS), which includes significant increases in payment for some procedures. "Capture of these charges depends on sufficient documentation," she underscores.

Here are some ways you can improve nursing documentation:

Develop your own system for facility coding.

Shaeffer notes that CMS has directed EDs to develop their own systems for facility coding, with the following requirements:

— that the services furnished be documented and medically necessary;

— that the system maps the services to the different levels of effort represented by the codes;

— that the code assigned should reasonably relate the intensity of hospital resources used.

These requirements may be fulfilled by using a point system, a clinical intervention model, or another method that clearly differentiates the levels of service, she explains. Whatever system is selected, it must be tested to determine how reliable it is, says Shaeffer.

Review the requirements of hospital policies, state law, and accreditation organization requirements, says Shaeffer, and outline documentation guidelines for the ED. "This can serve as the basis for education and auditing," she adds.

According to the proposed OPPS rule, CMS will allow facilities to continue to use their own coding methodology for assignment of visit levels instead of establishing a standard methodology, Shaeffer notes.

"The documentation and method go hand in hand," she says. "If facilities have not adopted or developed a method, they should do so, since CMS is not planning to devise theirs until 2004."

Document route of administration

Make sure all charges are captured.

Your documentation must be thorough to avoid loss of reimbursement, says Shaeffer. She gives the example of documenting "meperidine 50 mg" without documenting the route of administration. "If the medication was given intravenously, this would result in a $43.17 lost charge next year," she says.

Inadequate documentation also can cause your ED to lose out on the appropriate visit level, she adds. She explains that if you are using a point system to calculate the facility visit level, resource points are added to arrive at the total number of points, which is compared with the minimum point requirement for each visit level. Additional resource points are added for specific tasks or services, such as a visit from social services, says Shaeffer.

Therefore, if a service was performed but not documented, a lower level of service would have to be assigned, she says. She gives the following example: If additional points are earned when the patient arrives by advanced life support transport, then you must document this means of arrival.

"Likewise, if additional points are earned when a patient is placed in restraints, this should be documented," says Shaeffer.

Give feedback to nurses.

Whatever methods of documentation and coding are implemented, the records should be audited for documentation as well as coding quality, Shaeffer notes.

"Feedback should be given to the nursing staff about documentation deficiencies," she says.

Develop a nursing documentation tool.

Shaeffer recommends using nurses’ notes that are bar-coded and generated from a computerized system. "After care is delivered and documented, the nurses’ notes can be scanned into the system, where they are automatically matched to the patient encounter," she says.

Once optically imaged, the nursing documents and others can be accessed for subsequent patient visits, callbacks, coding, and quality assurance, notes Shaeffer.

The advent of APCs was a strong incentive to improve nursing documentation, says Shawn Keenen, director of the ED and float pool at Mongalia General Hospital in Morgantown, WV.

"Government institutions are making reimbursement tighter and are refusing payment for lack of documentation," he says. "We felt a tool was needed to assist the nursing staff in ensuring their documentation was complete."

All ED nurses listed interventions provided for patients, which were incorporated into a single-page form, he says. The nurse circles the points indicated for the intervention, and the biller/coder adds them and determines the level of charge by the total points.

"While the form is not exhaustive, it covers just about everything," says Keenen, adding that the form jogs the memory of busy nurses who may have forgotten what they have done for a patient. "Essentially, the form becomes an audit trail for their documentation."