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, but charge capture cards are a great low-tech alternative.  
 
2. Check the census information against the number of charges. Ask the hospital to fax you a census for all of your physicians each day. If it's easier, have each of your physicians bring you their daily census sheet. Go through and make sure you have charges for all the patients listed. If you find a patient with no charges, Buechner says, discuss with the doctor what services he provided and what charges he could have missed. You may ask for a discharge face sheet and check that against all the charge capture cards that the physician has turned in to your billing office or against the doctor's dictations. Periodic auditing of your hospital charge claims also helps to catch missed charges and reveal the cause of such oversights.
 
Tip: Some practices find it easier for their doctors to use the daily census sheet to track their inpatient services. It can serve the same function as a charge capture card.

Miscommunication Causes Diagnosis Code Errors

Problem: If your practice has multiple doctors doing inpatient rounds at the hospital, there's a good chance that miscommunication is causing inconsistent documentation and unreported charges. Diagnoses can change over the length of a patient's stay, and getting the correct diagnosis codes coordinated between doctors and for the correct date of service is especially important. 
 
"In some cases, practices are not getting reimbursed properly for inpatient services because [the services] were never charged," says Catherine Brink, CMM, CPC, president of HealthCare Resource Management Inc. based in Spring Lake, N.J. "But many times, the claims are getting denied because the procedure codes were not linked to a correct diagnosis code for that particular date of service."
 
Solution: Ideally, the primary doctor should take detailed notes and give the next doctor a quick briefing in order to coordinate care and diagnosis codes, Verno says. During a busy day, unfortunately, doctors may not even see each other to share information. Therefore, placing a special slip (e.g., an enlarged hospital-charge capture card) in the patient's chart can be a great way to ensure "that every doctor is checking off of the same sheet," Buechner says. Using a slip in the chart in addition to the charge capture cards is probably the best way to boost communication between doctors and ensure all charges get reported.
 
Of course, you'll first need to be in touch with the hospital to see what your doctors will be allowed to put in charts. Every hospital has its own medical records committee, Buechner says, and a list of what it's approved to go in the charts. It may be easier for a large practice to put its own slip in the charts because its providers are seeing a fair percentage of the hospital's patients. 
 
"A lot of this depends on relationships developed between the practice and the hospital," Buechner says. Regardless of the size of your practice, this is a good opportunity to improve your communications with the hospital. Tell them you're trying to improve your hospital charge-capture system and could use their help. 

No Payment Without Prior Authorization

Problem: Providers often lose revenue when they respond to an inpatient call without first getting authorization from the patient's insurance. Unauthorized insurers will often refuse to pay, and "it's hard to appeal a denial if the doctor didn't get prior authorization," Verno says. You can educate your physicians about how to avoid this mishap.
 
Solution: A physician should always call his office staff and get them to phone in a request for authorization to a patient's insurer. It's "one of the first things a physician should be doing when he's called by a primary- care provider to care for an inpatient," Verno says. Normally this should take only a few minutes. Then the physician can be confident of receiving payment when he cares for the patient. And he can assure the patient that he is authorized by his insurance company.
 
Physicians can also do financial harm to patients by seeing them without authorization. "Doctors should be wary of saying [to patients] 'Don't worry about if we're with your carrier,' because the carrier will often deny paying for treatments that weren't authorized," Verno says. 
 
If your claim has been denied, you may be able to appeal by checking if the hospital got prior authorization,  Verno says.