Documentation can be a headache for everyone, from the physicians who have to take precious time away from patients to document in the EHR to the case managers who have to track the physicians down to fill in gaps when information is missing from the medical record.
The case manager plays a crucial role in helping to make sure medical record documentation not only supports billing and coding to ensure accurate reimbursement, but also clearly communicates the patient's condition to the entire clinical team.
It needs to be complete, accurate, succinct, and effective, says Glenn Krauss, BBA, RHIA, CCS, CCS-P, PCS, FCS, CPUR, C-CDI, CCDS, director of enterprise solutions at Zirmed. However, it's often anything but. Krauss says he often comes across documentation that case managers could help clarify, and he recently offered some real-life examples (with details changed to protect patient privacy) to illustrate key points.
Case managers can help resolve common problems found in patient charts, including insufficient clinical information and missing basic information.
The readmission rate is dropping, but are hospitals just doing a quick shuffle--shifting patients from inpatient status to observation services--to make that change happen?
The study "Readmissions, Observation, and the Hospital Readmissions Reduction Program" published in the February 24 issue of the New England Journal of Medicine says that is not the case. The decline in readmissions is real, says the study, and likely in response to the Hospital Readmissions Reduction Program (HRRP), which fines hospitals for excessive readmissions.
CMS implemented the HRRP in 2010 in an effort to save the government money on the $17 million in estimated avoidable costs incurred each year from unnecessary hospital readmissions and to spare patients the poor outcomes that send them back to the hospital after they are discharged home.
The readmission rate has declined since the implementation of HRRP. But at the same time, some pointed to the fact that use of observation services was increasing and wondered if the two were connected. Others questioned whether the HRRP was actually making a difference in readmission rates, which were already on the decline before the program went into place.
The findings of this study validate what some case managers say they knew all along.
"Personally, as a director of case management I have never seen observation status used to avoid the readmission penalty," says June Stark, RN, BSN, MEd, director of care coordination at St. Elizabeth's Medical Center, Steward Healthcare in Boston.
OCR's long-awaited Phase 2 HIPAA Audit Program is finally in full swing. On March 21, OCR announced that it will begin verifying the contact information of covered entities (CE) and business associates (BA) selected for audits (www.hhs.gov/hipaa/for-professionals/compliance-enforcement/audit/phase2a...). This shouldn't surprise savvy healthcare organizations. The audits kicked off after a flurry of activity from OCR and HHS, including pricey HIPAA settlement fines and the publication of user-friendly HIPAA guidance for providers, developers, and patients.
Few in the healthcare industry would argue that the way the government currently pays for drugs is the most cost-effective, efficient, and equitable method possible.
Accurate patient matching within the EMR should not be a concern limited to HIM professionals. Ensuring that medical record data is correct and complete and that duplicate records are not created is key to various healthcare initiatives, including population health management, analytics, information governance, patient-centric care, health information exchanges, and finance. It all starts with the patient's record. Reducing the number of duplicate records at a hospital and being able to effectively match records is critical to ensuring that these healthcare initiatives are successful, says Lesley Kadlec, MA, RHIA, CHDA, director of HIM practice excellence for AHIMA.
"Patient matching is really the underpinning of all the strategic initiatives that are going on in healthcare," Kadlec says. "You have to have accurate patient information to have accurate patient care. Ensuring that you have the right patient and the right information at the right time is really what drives the physicians' and clinicians' ability to actually provide that patient with care."
More than half of HIM professionals work with mitigating duplicate patient records, and of that group, 72% do so on a weekly basis, according to a recent survey of AHIMA members. Unfortunately, less than half of all respondents have quality assurance in place for their registration or post-registration processes. (A summary of the data is available in the Journal of AHIMA.)
"The challenge is having the staff to be able to dedicate to making the corrections, doing the matching, and ensuring that everything is getting put back together," Kadlec says.
Patient matching and duplicate records are a major issue right now because hospitals are using so many different systems and there is often a lack of information governance across those systems, says Megan Munns, RHIA, identity manager at Just Associates, Inc., based in Denver.
CMS proposed an extensive five-year, two-phase plan to overhaul Part B drug payments for physicians and hospitals in March outside of the normal OPPS rulemaking cycle that could be implemented as early as this fall.
