Make Every Penny Count by Auditing Clinical Charts

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Karen Utterback By Karen Utterback 
Former Vice President, Product Marketing and Strategy, McKesson (Retired)

Clinical Chart Auditing Helps Agencies Pinch PenniesBecause the threat of ADRs and ZPICs is real for home health agencies, you should adopt an agency-wide plan to conduct internal clinical chart audits.

Those wise words come from Trudy Easton, senior clinical consultant at McKesson. A comprehensive auditing process can eliminate payment delays and denials caused by inadequate charting, Easton says.

The top home health survey deficiencies cited in 2011 were caused by not having the initial face-to-face assessment to determine eligibility, therapy assessment or reevaluation and SOC/ROC issues. On the hospice side, top deficiencies were lack of eligibility and failure to include Certificate of Terminal Illness.

Auditing charts can be a snap with the appropriate home care software, but getting aides, clinicians, therapists and billing staff on the same page to reduce delays and denials can be tougher.

What CMS is looking for in most cases is clear documentation that is detailed and measurable. It’s not enough, for example, to write that the patient was short of breath. What was the patient’s O2 saturation level? Was the patient using supplemental oxygen? If so, how much and by what delivery method?

Examining the hospice Certificate of Terminal Illness more closely, top reasons for delays or denials include failure to complete the documentation within an appropriate time frame, lack of narrative by the medical director supporting the diagnosis, and a prognosis of six months or less. Clinical charting software can help remind your workers to complete needed items in a timely fashion or prompt others to act, Easton says.

Once you’ve determined your agency’s top deficiency items, dive deeper into each to find out what you can do to increase compliance. This likely will include staff training. During that training, you should focus both on how to document properly and on why this is important to increase the rapport between workers and managers.

In these times of tightening reimbursements, every penny counts. Being able to count more of those pennies starts with clinical chart auditing.

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