Automated documentation error detection and notification improves anesthesia billing performance

Autor: Shaji Anupama, Stephen F. Spring, Warren S. Sandberg, John L. Walsh, Douglas E. Raines, William D. Driscoll
Rok vydání: 2007
Předmět:
Zdroj: Anesthesiology. 106(1)
ISSN: 0003-3022
Popis: Background: Documentation of key times and events is required to obtain reimbursement for anesthesia services. The authors installed an information management system to improve record keeping and billing performance but found that a significant number of their records still could not be billed in a timely manner, and some records were never billed at all because they contained documentation errors. Methods: Computer software was developed that automatically examines electronic anesthetic records and alerts clinicians to documentation errors by alphanumeric page and email. The software’s efficacy was determined retrospectively by comparing billing performance before and after its implementation. Staff satisfaction with the software was assessed by survey. Results: After implementation of this software, the percentage of anesthetic records that could never be billed declined from 1.31% to 0.04%, and the median time to correct documentation errors decreased from 33 days to 3 days. The average time to release an anesthetic record to the billing service decreased from 3.0 0.1 days to 1.1 0.2 days. More than 90% of staff found the system to be helpful and easier to use than the previous manual process for error detection and notification. Conclusion: This system allowed the authors to reduce the median time to correct documentation errors and the number of anesthetic records that were never billed by at least an order of magnitude. The authors estimate that these improvements increased their department’s revenue by approximately $400,000 per year. TO obtain reimbursement for anesthesia services in the United States, clear and complete billing documentation is required. This documentation includes specific time and event elements relating to the preanesthetic evaluation, intraanesthetic management, and postanesthetic care. The absence of even a single element or the presence of a wrong element can lead to the rejection of a claim for services rendered. Therefore, it is important that anesthesia practices identify and correct such documentation errors on anesthesia records to maximize revenues. Beyond its primary importance for revenue generation, billing documentation can also provide valuable evidence of proper medical care. 1 Achieving the goal of clear and complete documentation in every anesthetic record is a challenge, particularly in settings where anesthesiologists simultaneously direct the care of multiple patients and their primary focus of attention is on patient care and teaching. The advent of computerized anesthesia information management systems (AIMS) provides opportunities to develop novel tools and solutions to persistent problems in anesthesia practice, especially those related to consistent task execution and completion. Recently, it has been demonstrated that computerized automatic process monitoring and automatic alerts yield clinically important improvements in outcomes when applied to medical orders. 2,3 This suggests that other aspects of the care process, including seemingly mundane tasks such as billing documentation, would benefit from this approach. In the beginning of 2003, our department transitioned from recording intraoperative patient data using pen and paper to using an AIMS (Saturn; Draeger, Telford, PA) for documentation. The primary purpose of this transition was to facilitate correct data capture, 4 to minimize recording errors, 5 and to reduce the cost and time associated with generating bills by simplifying the billing process. However, after the transition to this system, it was apparent that a significant number of our records could not be submitted for payment even months after the date of service because they contained deficiencies and errors related to documentation that precluded billing. We hypothesized that we could reduce documentation errors, improve billing performance, and capture lost revenue by developing software and instituting a computerized system that would automatically search electronic anesthetic records for documentation errors and alert anesthesia personnel in near real time. This report describes this system, its implementation, and its impact on our documentation and billing performance.
Databáze: OpenAIRE
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