Reader Question: Improve Documentation

Question: My practice management group wants to accommodate the hospitals needs and preserve good working relationships, so we want to do what we can to help with the APC system. As an ED physician, what should I do to improve my documentation?

North Carolina Subscriber

Answer: The documentation of the overall episode of care will be important to the ambulatory payment classification (APC) system. Procedure notes will be significant to help coders identify the procedures and levels of complexity of each procedure and/or service that must now be identified with a HCPCS procedure code for the technical billing component of the emergency department (ED) visit.

Also, special emphasis should be given to the orders to nursing staff, direct patient monitoring and the overall ED course with the treatments and the patients response to the treatments. In general, the physicians medical decision-making component, which, to a large extent, includes elements also related to nursing involvement, will be important.

To bill appropriately for both a facility evaluation and management service and a procedure (requiring modifier -25 significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), physicians will have to clearly establish the significant and separately identifiable service through their documentation of the overall service. Emergency physicians should work with the ED nursing staff to assure a cooperative effort to improve both physician and nursing documentation.

Coordination with the coders responsible for assigning ED codes also will be important.

Remember the importance of medical staff documenting their services, particularly procedures, because they also will be identified for the technical billing component. You may want to post a reminder/notice at the nurses station that addresses the importance of all documentation for the emergency department.


- Published on 2000-11-01