Practice Management Alert

Many practices worry that they are losing money due to improper documentation and missed charges on inpatient care. Worry no more: Here are the solutions to three major problems associated with hospital visits.  Poor Documentation Means Services Are Not Billed Problem: One or more doctors in your practice may be creating a nightmare for your billing office by not documenting and tracking inpatient visits properly. It's common for physicians to get pulled in a million directions once they set foot in the hospital, causing them to forget to write down every service provided. And some doctors are remiss in their documentation because they just don't understand how to choose a level of service and don't see how it will affect them. Often this means they are also remiss in tracking inpatient services on a daily basis. This is where you step in.
 
Solution: Make sure your doctors realize that if they don't write it down, they won't get paid for it, says Quin Buechner, MS, M.Div, CPC, president of ProActive Consultants based in Cumberland, Wisc. Educating your physicians on proper documentation is the first step. "A great rule to follow is to document your chart as though you were going to go to court," says Steven Verno, NREMTP, CMBSI, director of reimbursement at Emergency Medicine Specialists in Hollywood, Fla. This way, all the evidence needed to back up claims will be in one place and easily accessible to billing staff in case you need to check, he says.
 
Here are two key strategies you can adopt within your billing office to make sure every service is documented and every charge is captured daily:
 
1. Create a separate charge capture card for hospital visits. Many practices have an encounter form or capture card for office visits and surgeries, but not for hospital visits. A separate card will help ensure that E/M codes for inpatient, follow-up, emergency room and consultation visits get reported to your practice's billing office. 
 
The card should include spaces for the patient's name and date of birth, place of service, date of visit, date of procedure, a list of hospital E/M codes commonly used by your providers, and space to write diagnoses. These cards are usually 3x5 or 4x6 inches - just the right size to fit in a physician's lab coat, Buechner says. Prevent them from being lost or forgotten by requesting that your physicians turn them in daily.
 
Some physicians are already using palm pilots to do their dictations and record hospital visit charges. The information can then be shared by printing out copies to put in the patient chart and to give to the billing office. Palm pilots and electronic access to information are probably the most efficient system, [...]