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Physician narrative must be carefully evaluated
Offer examples of notes that meet CMS standards
[Editor's Note: This is the second of a two-part series examining some of the regulatory and financial changes faced by hospices during recent years. Last month's article looked at the increased need for technology to manage hospice billing and data collection. This month we look at how agencies have met the challenge of physician notes in records, staff training, and management of increased administrative tasks.]
One of the more challenging requirements for hospice in 2010 has been the physician narrative required for certifications and re-certifications, but two hospices are addressing the challenge with physician education and electronic records.
"We cover about one-fourth of the state of Kansas, and we only have one full-time medical director and some part-time community physicians who handled certifications for us," says Renee Hahn, chief financial officer for Harry Hynes Memorial Hospice in Wichita, KS.
A new electronic records system enables physicians to document directly into the medical record system, as compared to being able to only read a record with the previous system, Hahn says. "We included the physicians in our transition to the new technology so they are comfortable with the system," she adds.
Even if your hospice has an electronic medical records system that makes documentation simpler for the physicians, be sure you monitor the narratives and offer suggestions on items to include, suggests Carla Braveman, BSN, RN, MEd, CHCE, president and chief executive officer at Big Bend Hospice in Tallahassee, FL. "Our medical director has provided educational sessions for physicians that include examples of good and bad documentation for recertifications," Braveman says. "The key point is that it has to be a narrative, not just a checklist of items."
In addition to educating physicians, Braveman and her medical director review narratives in the records. "I read some of them; the medical director reads all of them," she says. "This is not an exact science, and each patient is different, but there are some key areas for prognosis that must be addressed." Functional status, medication status, and weight loss should always be included in the narrative, she says.
When a review of the narrative falls short of what the Centers for Medicare and Medicaid Services (CMS) requires for certification or recertification, the medical director contacts the physician with suggestions for improvement, says Braveman. "The ideal situation is to formalize and standardize in a way that we don't overburden the physicians," she says.
Find ways to do more with less
Physicians aren't the only ones that hospice managers don't want to overburden. Hospice managers also are looking at redefining staffing and job responsibilities to handle the additional administrative responsibilities without overburdening staff members.
"Staff training is ongoing because our administrative requirements keep increasing," says Hahn. "For clinicians, the additional requirements, and the constant changes, create more non-productive time that does not necessarily translate to improved patient care."
One reason for constant changes is the lack of explanation for CMS requirements when they are first published, says Hahn. "CMS will issue a directive, then months later, a clarification will be issued," she says. This means that hospices that interpreted the initial directive one way might have to change what they are doing when a clarification is issued, Hahn says. "Nurses get frustrated, but we all realize that change is the reality of our lives today," she adds.
Although Hahn has not added staff to handle the additional administrative burdens in the office, she points out that job responsibilities have changed. "We've shuffled jobs and parceled out different responsibilities to those who can take on extra work," Hahn explains. "We've redefined priorities according to the time sensitivity of different deadlines."
For example, her hospice serves as a beta site for their software vendor, so the team that works with the vendor must spend time on phone calls and meetings to evaluate the program, explains Hahn. "I have to evaluate the value of their time spent on this project versus the burden it places on the hospice if other activities are not completed," she says. Because a software system that accurately collects data and promotes quicker payment of claims is valuable to the agency, these employees are able to make this responsibility a higher priority than other internal deadlines.
"We've got to get paid, so anything related to claims being submitted accurately and in a timely manner will take priority," Hahn says. "We want to make sure we do it right the first time."