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Education, auditing key to documentation programs
Multiple review levels assure records are accurate
Regular audits and continuing education are the keys to a successful documentation assurance program, says Liz Youngblood, RN, MBA, vice president, patient care support services at Baylor Health Care System in Dallas.
The Baylor system has developed multiple levels of review for its documentation assurance program. In addition, the care coordination and coding staff go through formal training to ensure the accuracy of the documentation in the medical record.
All hospitals in the Baylor system practice documentation assurance, and seven of those participate in a formal, structured program. These hospitals use different models depending on what is most effective at the individual hospital. The larger hospitals have dedicated DRG assurance nurses who work with the care coordinators on documentation assurance, adding an extra layer of expertise.
At smaller hospitals, the care coordinators are responsible for documentation assurance as part of their regular duties.
A robust auditing process is essential to make sure that your documentation and coding is up to date, Youngblood says.
The Baylor health system contracts with an external firm, which comes in quarterly and runs reports on the documentation integrity program as well as conducting an annual audit. Another external agency conducts a quarterly audit.
In addition, the hospital system's in-house coding auditors regularly review hospital medical records for coding accuracy. System-based coding auditors also audit the medical record for coding.
The coders and care coordination staff at each hospital get together regularly to review medical records that might be in question and decide if anything could have been done differently.
"We also have daily communication between the coding staff and the care coordination staff who help with ensuring that documentation is complete on the medical records," Youngblood says.
Internal, external reviews necessary
Youngblood suggests that hospitals put parameters in place to assure that they are monitoring their own documentation and coding integrity as well as consulting with someone outside the organization to audit the records on a regular basis.
For instance, if you are in a health system or partner with other hospitals, you could audit each other and exchange expertise, she suggests.
"Ideally, any review of documentation can be done internally but hospitals should also have an external review on a periodic basis. It doesn't have to be an expensive ordeal. You just need a different pair of eyes — some kind of outside objective review to make sure you don't perpetuate the same practices," Youngblood says.
If you're doing something that is not a best practice, you might not recognize it or pick up on it if you continue to review yourself, she points out.
If you choose to conduct your audit internally, make sure that whoever you choose to conduct your audit is looking at your documentation from a different angle, Youngblood suggests.
In addition, make sure that your documentation assurance and coding staff are educated regularly, as coding requirements change, she advises.
"The benefit of accurate coding is not necessarily tangible, but having fewer errors on the back end means that when an external agency reviews medical records, the hospital will have fewer errors that minimize the need to rebill," Youngblood adds.
At Baylor, the care coordinators receive formal training on documentation issues on an annual basis, in addition to attending regular educational sessions with the coding department.
In addition, the health care system has a coding educator who provides education for the staff at each hospital. The larger hospitals in the Baylor system have DRG assurance nurses who oversee the documentation integrity process and provide additional education.
"The education also extends to the medical staff at staff inservices and section meetings. The coders and care coordinators also provide just-in-time education to the physicians when they query them in person," Youngblood says.