CHICAGO—Coding is essential to helping gain proper reimbursement during the billing process; however, proper documentation may actually be the key to optimizing revenue and capturing patients' acuity and severity of disease, according to a poster presentation last week at the annual leadership conference of the American College of Cardiovascular Administrators.
Clyde Meckel, MD, of the BryanLGH Heart Institute in Lincoln, Neb., and colleagues set out to train cardiologists and cardiothoracic surgeons on documentation requirements to see whether proper documentation would capture a patient’s true acuity and severity of illness.
To do so, the researchers retrained cardiovascular documentation specialists to educate physicians and staff. The facility hired two full-time consultants to work on-site for 30 days over a nine-month period.
The two consultants reviewed charts for documentation accuracy and also provided group training on documentation guidelines to physicians on staff. The consultants, after reviewing the charts, presented recommendations on how staff could improve documentation and how to document properly.
Staff at BryanLGH found that a potential $1.4 and $1.7 million could be realized if documentation was properly carried out. With proper documentation, the facility realized actual addtional revenue that equated to more than $1.5 million annually.
“Providing documentation assistance to BryanLGH Heart Institute cardiologists and cardiothoracic surgeons increased the case-mix index,” the researchers wrote. “This engagement opened the door for medical records staff to work more closely with physicians in their documentation and query physicians more consistently.”
The researchers noted that as coding and documentation rules change, facilities must retrain staff to help improve their documentation efforts in order to capture “100 percent of the procedures performed.”
The consultants also completed one-on-one education and follow-up education as necessary during and after the process.