Here’s Looking at You and You, and You, Kid

HSMN has had reports from several of its client hospitals asking us to come in and review cases that have been identified for audit.  These have not been RAC audits but reviews by third party payors who want to compare the hospital documentation and coding to the physicians who performed the service and or the procedure.

HSMN formulated an approach several years ago when it found that there were potential discrepancies between what the hospital claimed to have taken place and what the physician documented.  In almost all of these cases under review both the hospital and the physician would have had to return their reimbursement.  But HSMN reviewed everything about each “case” and went back through the documentation trail, interviewing each of the persons who touched the documentation from receptionist, nurse, resident, attending, coder, and biller to discover that some of the differences were the result of poor communication, ineffective work models and just plain human error.

Once we had the information from the “sources” and places of care, we deconstructed the documentation and found that the differences were apparent but not intended.  In one case the payor paid a claim that indicated a certain bilateral procedure (not Medicare); in actuality there was one major procedure and fix at another site that was minor.

It became clear that on this medical staff and especially among the House Officers, clinical decision making and clinical documentation did not match.  Furthermore, coders of varying degrees of experience made assumptions about the procedure the physician performed without a close look at the diagnosis and anatomical descriptors.

HSMN used the opportunity of its pre audit reviews to bring together in an interactive media a methodology for each of the participants in the “provision” of service to better understand what had actually happened as part of the service.  HSMN began a program of “Clinical Documentation Improvement” including carefully reviewing “Cut and Paste” methodology used in some institutions using the Electronic Medical Record.  The reason is simple enough. The premise is that no two patients are the same even though the procedure or service may be assumed to be the same.

HSMN reconstructed each case for teaching purposes to show the clinicians and members of the Revenue Cycle Team what the proper flow of documentation should have been.  We are now letting all of our clients know that third party payors are going to be looking at the patient Medical Record to see if that patient is seen and documented by both the hospital and the physician in a way that makes it clear that it is the same patient, and everyone agrees on what service and procedure took place.

HSMN’s recent work doing clinical documentation reviews and coding for its clients on an outsourced basis has proven fruitful as the internal staff start the ICD 10CM/PCS transition.  HSMN provides detailed feedback, risk assessment and root cause analysis that provides the underpinning for the training that is going to be received in the transition.

For 28 years HSMN has worked with the entire revenue cycle staff and the clinicians with very successful outcomes.

For more information about what HSMN has done please go to the web site or call 866-908-4226866-908-4226.