The ambulatory surgery center business office and clinical core are often considered separate spheres, but documentation gaps and errors can affect both. "These problems can cause significant coding mistakes, and cost your facility thousands of dollars each year in lost reimbursement. They can also expose ASCs to potential compliance risks — all of which are preventable," says Stephanie Ellis, RN, CPC, founder and president of Ellis Medical Consulting. Ms. Ellis describes four issues that arise in the ASC arena and how to course correct for proper, effective documentation.
1. Operative report templates. "Sometimes with surgical procedures, the physician utilizes a 'canned' operative report in the record, instead of doing an individualized OP report tailored to that patient and the procedure performed," says Ms. Ellis. This type of template, while saving time for physicians, exposes an ASC to the risk of incomplete documentation. Medicare does not encourage the use of this type of record; they may even be considered "cloned records.", which is a fraud and abuse issue.
Physicians can use templates, if they allow for individualized documentation. Complete operative reports contain information particular to each patient procedure such as:
• Any patient complications
• Any procedure complications
• Any changes in medication
• Laterality
"If the report is not accurate, detailed and individualized, it can cause recoupment, problems with the facility's state survey and/or it could be a potential malpractice issue for both the surgeon and facility," she says.
Even if a physician chooses to use individualized templates, Medicare signature requirements dictate that healthcare providers may not use signature stamps to sign any medical record documents. Documents must be physically signed or electronically signed through an EMR.
2. Error correction. Every person contributing to the medical record, physicians and nurses, must sign and provide a full date. While errors are bound to occur, there is only one correct way to rectify a mistake. "The proper way to correct an error in the medical record is to make a single line through the error in ink, write the word 'Error' above it, make the correction and initial the change," says Ms. Ellis.
3. Physician dictation and missing operative reports. Physicians are pulled in many different directions, with rarely a moment to spare, but it is important for administrators to stress the necessity for timely dictation and operative reports. "Physicians should realize that there are financial and compliance consequences to slow or late dictation," says Ms. Ellis. Cash flow suffers and procedures billed without an operative report can cause further complication; Medicare may consider such a claim as fraudulent.
4. Offsite dictation. Physicians split their time between many different locations, but compliance issues can arise when physicians dictate offsite. If operative reports list the name of a physician's clinic or hospital, rather than the ASC where a procedure was performed, the procedure's location won't match in the operative report and claim. Medicare could consider this a fraudulent claim.
5. Inaccurate codes in OP reports. Some physicians offer highly detailed operative notes, including CPT codes. "This does not relieve the coder from the obligation of examining the entire OP report to be sure the codes given are correct," says Ms. Ellis. To ensure clean claims documentation must be complete and coding accurate before billing a procedure.
Solutions
1. Guidelines. Put in place specific guidelines for tracking documentation compliance. "These issues should be followed up on regularly and have designated ASC staff who will use considerable diligence in assuring OP Reports are completed in a timely manner and placed in the charts, and all documents are signed in a timely manner," says Ms. Ellis.
2. Physician report cards. Keeping a "report card" of each ASC physician's documentation can help identify any reoccurring issues and serve as visible way for physicians to measure their documentation performance. In addition to operative reports, useful documentation areas to track include:
• Physician orders
• H&Ps
• Consents
• Intra-operative records
• Progress notes
• Discharge orders
Timeliness, level of detail and proper signatures are helpful areas to "grade."
3. Plan of action. Physician report cards are a useful tool, but as with any data they need to be put to work. Create a system with specific actions for physicians routinely receiving poor report cards or failing document audits. If necessary, tie privilege suspension to continued failure to comply with documentation requirements, says Ms. Ellis.
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