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Conference Name: Successfully Reduce Delinquencies: Proven Techniques from the Trenches
Scheduled Conference Date: Tuesday, May 10th, 2005
Scheduled Conference Time: 1:00 p.m.–2:30 p.m. (Eastern), 12:00 p.m.–1:30 p.m. (Central), 11:00 a.m. – 12:30 p.m. (Mountain), 10:00 a.m.–11:30 a.m. (Pacific)
Scheduled Conference Duration: 90 Minutes
PLEASE NOTE: If the audioconference occurs April through October, the time reflects daylight savings. If your area doesNOT observe Daylight Savings, times will be one hour earlier.
Your registration entitles you to: ONE telephone connection to the audioconference. Invite as many people as you wish to listen to the audioconference on your speakerphone.
Permission is given to make copies of the written materials for anyone else who is listening.
In order to avoid delays in connecting to the conference, we recommend that you dial into the audioconference 15 minutes prior to the start time
Dial-In Instructions:1. Dial 877-407-2989 and follow the voice prompts.2. You will be greeted by an operator3. Give the operator your pass code 051005 and the last name of the person who registered for the audioconference.4. The operator will then verify the name of your facility.5. You will then be placed into the conference.
Technical Difficulties1. If you experience any difficulties with the dial-in process, please call the Conference Center reservation line at
877-407-7177.2. If you should need technical assistance during the audio portion of the program, please press the star key followed by
the 0 key on your touch-tone phone and an operator will assist you. If you are disconnected during the conference, dial877-407-2989.
Q&A Session1. To enter the questioning queue during the Q&A session, callers need to push the star key followed by the 1 key on their
touch-tone phones. Note: This portion of the program generally falls after the first hour of presentation. Please do nottry to enter the queue before this portion of the program.
2. If you prefer not to ask your question on the air, you can fax your question to 877-808-1533 or 201-612-8027. (Please note: You can only fax your question during the program.)
Prior to the programIf you prefer not to ask your question on the air, you can send your questions via email to [email protected]. Cutoffdate and time for questions: 05/09/05 @ 5:30 PM EST. Please note that not all questions will be answered.
Program Evaluation Survey In your materials on page 2, we have included a Program evaluation letter that has the URL link to our program survey. Wewould appreciate it if when you return to your office you could go to the link provided and complete the survey.
Continuing Education documentation If CE’s are offered with this program a separate link containing important information will be provided along with the pro-gram materials. Please follow the instructions provided in the CE Documentation.
Dial-In Instructions
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200 Hoods Lane PO Box 1168 Marblehead MA 01945 TEL 781 639 1872 FAX 781 639 7857 URL www.hcpro.com
Program Evaluation
Dear Audioconference Participant,
Thank you for attending the HCPro audioconference today. We hope that you find theinformation provided valuable.
In our effort to ensure that our customers have a positive experience when taking part inour audioconferences we are requesting your feedback. We would also like to request thatyou forward the link to others in your facility that attended the audioconference.
We realize that your time is valuable, so we’ve limited the evaluation to a few brief ques-tions. Please click on the link below.
http ://www.zoomerang.com/sur vey.zg i?p=WEB224B3DGBY85
The information provided from the evaluation is crucial towards our goal of delivering thebest possible products and services. To insure that your completed form receives ourattention, please return to us within six days from the date of this audioconference.
We appreciate your time and suggestions. We hope that you will continue to rely on HCProaudioconferences as an important resource for pertinent and timely information.
Sincerely,
Frank MorelloDirector of MultimediaHCPro, Inc.
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Successfully ReduceDelinquencies: Proven
Techniques from the Trenches
1:00 p.m.–2:30 p.m. (Eastern)
12:00 p.m.–1:30 p.m. (Central)
11:00 a.m.–12:30 p.m. (Mountain)
10:00 a.m.–11:30 a.m. (Pacific)
presents . . .
medical records briefingThe newsletter for health information management
A 90-minute interactive audioconference
Tuesday, May 10, 2005
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ii Successfully Reduce Delinquencies: Proven Techniques from the Trenches
In our materials we strive to provide our audience with useful, timely information. The live audioconference willfollow the enclosed agenda. Occasionally our speakers will refer to the materials enclosed. We have noticedthat other non-HCPro audioconference materials follow the speaker’s presentation bullet-by-bullet, page-by-page. Because our presentations are less rigid and rely more on speaker interaction, we do not include eachspeaker’s entire presentation. The materials contain helpful forms, crosswalks, policies, charts, and graphs. Wehope that you find this information useful in the future.
HCPro is not affiliated in any way with the Joint Commission on Accreditation of Healthcare Organizations,which owns the JCAHO trademark.
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iiiSuccessfully Reduce Delinquencies: Proven Techniques from the Trenches
The “Successfully Reduce Delinquencies: Proven Techniques from the Trenches” audioconferencematerials package is published by HCPro, 200 Hoods Lane, P.O. Box 1168, Marblehead, MA 01945.
Copyright 2005, HCPro, Inc.
Attendance at the audioconference is restricted to employees, consultants, and members of the medical staffof the Licensee.
The audioconference materials are intended solely for use in conjunction with the associated HCPro audio-conference. Licensee may make copies of these materials for your internal use by attendees of the audiocon-ference only. All such copies must bear this legend. Dissemination of any information in these materials or theaudioconference to any party other than the Licensee or its employees is strictly prohibited.
Advice given is general, and attendees and readers of the materials should consult professional counsel for specific legal, ethical, or clinical questions. HCPro is not affiliated in any way with the Joint Commission onAccreditation of Healthcare Organizations, which owns the JCAHO trademark.
For more information, contact
HCPro, Inc. 200 Hoods LaneP.O. Box 1168Marblehead, MA 01945Phone: 800/650-6787Fax: 781/639-0179E-mail: [email protected] site: www.hcpro.com
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iv Successfully Reduce Delinquencies: Proven Techniques from the Trenches
Dear Colleague,
Thank you for participating in our "Successfully Reduce Delinquencies:Proven Techniques from the Trenches" with Rose T. Dunn, RHIA, CPA,
FACHE, Eileen M. O’Heron, RHIA, and Andrea Dickey (moderator). Weare excited about the opportunity to interact with you directly and encour-age you to take advantage of the opportunity to ask our experts yourquestions during the audioconference. If you would like to submit a ques-tion before the audioconference, please send it to [email protected] provide the program date in the subject line. We cannot guaranteeyour question will be answered during the program, but we will do our bestto take a good cross section of questions.
If at any time you have comments, suggestions, or ideas about how wemight improve our audioconferences, or if you have any questions aboutthe audioconference itself, please do not hesitate to contact me. And if youwould like any additional information about other products and services,please contact our Customer Service Department at 800/650-6787.
Along with these audioconference materials, we have enclosed a fax eval-uation. We value your opinion. After the audioconference, please take aminute to complete the evaluation to let us know what you think.
Thanks again for working with us.
Best regards,
James HutchinsAudioconference ProducerFax: 781/639-2982E-mail: [email protected]
200 Hoods LaneP.O. Box 1168
Marblehead, MA 01945Tel: 800/650-6787Fax: 800/639-8511
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vSuccessfully Reduce Delinquencies: Proven Techniques from the Trenches
Agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vi
About your sponsors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii
Speaker profiles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Exhibit A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Presentation by Rose T. Dunn, RHIA, CPA, FACHE, and Eileen M. O’Heron, RHIA
Exhibit B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Operative record document
Exhibit C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Excerpt from More with Less: Best Practices for HIM Directors by Rose T. Dunn, RHIA,CPA, FACHE, HCPro, Inc., 2004
Exhibit D . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Articles taken from HCPro’s monthly newsletter Medical Records Briefing
- AL hospital turns around delinquent record rateCommunication, revised rules, facilitywide effort all help with dramatic reduction(April 2005)
- Delinquent records trouble spotSurvey shows 9% cited by JCAHO in this area(February 2005)
Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43
Contents
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vi Successfully Reduce Delinquencies: Proven Techniques from the Trenches
Agenda
I. Delinquency: Definitions and calculationsa. CMS v. accreditation agenciesb. What is an acceptable delinquency rate?
II. Health record content requirementsa. CMS v. accreditation agenciesb. Streamline and reconcile your bylaws, rules and regulations,
and policies
III. HIM department responsibility and timely record completiona. Processing timelinessb. Pros and cons of concurrent analysisc. HIM’s role in nonphysician deficiencies
IV. Case study (Rush Copley Medical Center): JCAHO s tracer method-ology process
V. Tips and Toolsa. Utilizing methods approved by CMS and JCAHOb. Making it fun for the physiciansc. Reducing obstaclesd. When the “carrot” doesn’t work
VI. How to gain administrative support
VII. Live Q&A session
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viiSuccessfully Reduce Delinquencies: Proven Techniques from the Trenches
About HCPro, Inc.
HCPro is the premier healthcare information and resource provider on compliance and regulatory issues facedby hospitals, home-health organizations, nursing homes, physicians’ offices, and other healthcare facilities.HCPro has launched a number of Web “supersites” that include tips, how-to information, “ask the expert”columns, free e-mail newsletters, and so much more.
About Medical Records Briefing
Medical Records Briefing is a respected monthly newsletter that provides the best new ideas in health informa-tion management (HIM), plus a whole set of professional resources to benefit the medical records department.Each issue is full of crucial information such as the latest Medicare changes; practical advice on tough legal,financial, privacy, and human resource issues; as well as real-life success stories from other managers.
Your subscription to Medical Records Briefing keeps you up to date on • the latest changes to JCAHO IM standards • coding and transcription management • documentation and physician relations • the latest final rules and OIG reports • HIM and the revenue cycle • HIPAA and the privacy and security of health information
With Medical Records Briefing, readers discover the latest industry developments and trends shaping the field ofHIM.
Some free subscriber benefits include:
• Regular benchmarking surveys of readers • MRB Talk—our Internet discussion group where readers can network with their peers • Fax express—whenever news happens that just can't wait, subscribers receive the pertinent information by
fax so they'll always be the first to know • A Minute for the Medical Staff—six times a year, Dr. Robert Gold addresses physicians to help them under-
stand the importance of coding and billing
Available online!
Save time and shipping costs by receiving your issue of Medical Records Briefing right on your computer with
About your sponsors
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viii Successfully Reduce Delinquencies: Proven Techniques from the Trenches
the click of a few buttons! We'll alert you via e-mail each month when your new issue is ready. Just order theelectronic version of the newsletter in the option box below. Order both our print and electronic versions byselecting “Print and Electronic” in the option box.
If you have questions regarding the coverage/content of this product, contact Senior Managing Editor Beth Easleyat [email protected]
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ixSuccessfully Reduce Delinquencies: Proven Techniques from the Trenches
Speaker profiles
Rose T. Dunn, RHIA, CPA, FACHE
Rose T. Dunn, RHIA, CPA, FACHE, is a former AHIMA president and recipient of AHIMA’s 1997Distinguished Member Award. She is chief operating officer of First Class Solutions, Inc., of St. Louis, MO.
Rose started her career as director of medical records at Barnes Hospital, a 1,200-bed teaching hospital inSt. Louis. She was promoted to vice president at Barnes and was responsible for more than 1,600 employ-ees and new business development.
After Barnes, she joined MetLife where she worked with managed care organizations nationwide on a varietyof operational, medical management, and network development issues. Rose also has served as a chieffinancial officer of a dual hospital system in Illinois.
She is active in several professional associations including AICPA, ACHE, HFMA, and AHIMA. She holds fel-lowship status in HFMA, ACHE and AHIMA. She is also a certified in healthcare privacy and security.She is the author of several texts, including Finance Principles for the Health Information Manager, More withLess, and Haimann’s Healthcare Management. In addition, Rose has published more than 200 articles and hasmade numerous presentations across the United States on a wide variety of topics.
Eileen M. O’Heron, RHIA
Eileen M. O’Heron, RHIA, is director of medical records at Rush Copley Medical Center in Aurora, IL, andhas held many positions over the past 23 years, including director of medical records at Morris Hospital inMorris, IL, and manager of medical records at Central Dupage Hospital in Winfield, IL.
Eileen recently successfully completed a JCAHO survey under the new tracer methodology process, andthe hospital demonstrated excellent compliance with the IM standards, including those involving delinquentmedical records.
Eileen is affiliated with AHIMA, the Illinois Health Information Management Association, and the ChicagoArea Health Information Management Association. She is currently a resident of Illinois. She received herbachelor’s degree in medical records administration in 1982 from Illinois State University.
Andrea Dickey
Andrea Dickey (moderator) edits the HcPro e-zines HIM Connection, EHR Connection, and ExecutiveBriefings Digest. She also writes for Medical Records Briefing and HcPro’s newest newsletter, ElectronicHealth Records Briefing.
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Exhibit A
Presentation by Rose T. Dunn, RHIA, CPA, FACHE, and Eileen M. O'Heron, RHIA
Disclaimer:Some of the information provided by Rose T. Dunn, RHIA, CPA, FACHE in this program may have beenshared at National AHIMA or CSA educational programs, or published in the journal of AHIMA orother publications
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EXHIBIT A
Successfully Reduce Delinquencies: Proven Techniques from the Trenches
1
Successfully ReduceDelinquencies: ProvenTechniques from theTrenches
Rose T. Dunn, RHIA, FAHIMA, Chief Operating Officer
First Class Solutions, Inc., St. Louis, MO
Eileen M. O'Heron, RHIA, Director Medical Records
Rush Copley Medical Center, Aurora, IL.
2
Why Should We Be ConcernedAbout Incomplete and
Delinquent Medical Records?
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Successfully Reduce Delinquencies: Proven Techniques from the Trenches
EXHIBIT A
3
Some of the Reasons
� Medico-Legal
� Business Record Rule
� Hinders Workflows
� Another place to look
� Delay in processing requests for copies
� Patient/Other
� Payer
� Quality of the record
� As it ages, the details become more gray
4
Some of the Reasons
� CMS
� Conditions of Participation
� Visit from the CMS Team
� 45 days to demonstrate resolution
� Sometimes as short as 7 days
� Lose Medicare reimbursement
� State
� Same rules as CMS or more stringent
� Lose facility licensure
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EXHIBIT A
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5
Some of the Reasons
� JCAHO (Joint Commission on Accreditation
of Healthcare Organizations)
� Triple whammy (IM6.10/LD1.30/MS3.20)
� Most frequent recommendations (6.10,6.50and
6.30 – also 3.10)
� HFAP (Healthcare Facilities Accreditation
Program) #5
6
Delinquency:Definitions and Calculations
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Successfully Reduce Delinquencies: Proven Techniques from the Trenches
EXHIBIT A
7
What is a Delinquent Medical Record?
� JCAHO/HFAP: 30 days from discharge
� CMS-COP: 30 days from discharge
� States: Vary—some as low as 14 days from
discharge
� Can’t use date of analysis
8
What is an AcceptableDelinquency Rate?
� CMS: 0%
� State: 0%
� HFMA Self Assessment: �5-10%
� 10% is achievable
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EXHIBIT A
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9
Calculating Delinquency Rate� JCAHO Formula
� First calculate the average monthly discharges—thedenominator
Average Monthly Discharge Rate (AMD):
� Total number of inpatient discharges in the 12 monthsprior to survey ÷ 12
� Rolling 12 month period
� This number represents all inpatient and can includeother records such as:� observation cases,
� ambulatory surgery,
� endoscopy,
� cardiac catheterization, or
� emergency department
� Must represent record types that are analyzed
� Does not include any other type of ambulatory/outpatientencounter
10
Calculating Delinquency Rate
� JCAHO Formula
� Second capture the delinquent record count—the
numerator
� The Delinquent Record Count
� Can be an average of delinquent counts for the month
� Can be the delinquent count at the end of the month
� Can be the delinquent count on the day of the MRC
� Consistent and Documented
� Count
AMD
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Successfully Reduce Delinquencies: Proven Techniques from the Trenches
EXHIBIT A
11
What is Complete?
� Your Bylaws
� Your Rules
� State requirements
� Federal requirements
� Don’t overdue it
12
Reducing the Count
� Rewrite Completeness Policy
� JCAHO’s minimum requirements for the content
of the medical record
� The JCAHO IM.6.10 standard, EP 5:
� Minimum to be authenticated:
� H&P,
� Operative Report,
� Consultation, and
� Discharge Summary
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EXHIBIT A
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13
Reducing the Count
� If these “four core elements” are not present
� Within 30 days of discharge,
� Counted as delinquent
� Flag other Items for completion
� Considered incomplete rather than delinquent
� Do not include them in the count
14
Reducing the Count
� If your analysis process is computerized,� Create a report to pull only the four core elements
� Greater than 30 days old to determine the delinquencycount
� Physicians do not have to know the differencebetween delinquent and incomplete items as youwant all of the items to get done!
� Only difference is the way you calculate the HospitalMedical Record Statistics form to determinecompliance with IM.6.10, EP10 based on yourhospital policy
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Successfully Reduce Delinquencies: Proven Techniques from the Trenches
EXHIBIT A
15
What is Complete?
Accreditation requirements� www.JCAHO.org (order standards)
� FAQs:http://www.jcaho.org/accredited+organizations/hospitals/standards/hospital+faqs/faq+index.htm
� www.HFAP.org (order standards)� FAQs:
http://www.jcaho.org/accredited+organizations/hospitals/standards/hospital+faqs/faq+index.htm
� COP requirements� http://www.access.gpo.gov/nara/cfr/waisidx_99/42cfr482_9
9.html
� http://www.cms.hhs.gov/cop/1.asp
� http://www.cms.gov/manuals/107_som/som107ap_a_hospitals.pdf
16
New Proposed CMS-COP Rules
� Federal Register 3/25/05
� H&Ps
� Verbal Orders
� Post Anesthesia Evaluation
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EXHIBIT A
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17
New Proposed CMS-COP Rules
� H&Ps -- 482.22(c)(5) and 482.24(c)(2) (i)� Current:
� H&P no more than 7 days prior or within 48 hours of admit
� By MD, DO, Oral Surgeon (when admit is for oral surgery)
� Proposed:
� Recognizes conflict with JCAHO’s 30 days allowance withupdate
� H&P must be completed no more than 30 days before or 24hours after admission (updated if prepared in advance ofadmission)
� By a MD, DO, or other qualified individual who has been grantedthese privileges by the medical staff in accordance with State law
� Placed in the records within 24 hours of admission
18
New Proposed CMS-COP Rules
� Verbal Orders – 482.23 (c)(2)(ii)
� Current:
� Must be signed or initialed by the prescribing practitioner
as soon as possible
� Telephone or oral orders
� Proposed:
� Combine terminology—verbal orders
� 482.24 (c)(1): All patient record entries must be legible,
complete, dated, timed and authenticated by whomever
is responsible for providing or evaluating a service
provided.
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Successfully Reduce Delinquencies: Proven Techniques from the Trenches
EXHIBIT A
19
New Proposed CMS-COP Rules
� Verbal Orders – 482.23 (c)(2)(ii)
� Proposed:
� All orders, including verbal orders, must be dated, timed and
authenticated promptly by the prescribing practitioner, except
� For the next 5 years (after the rule is final)—authenticated by the
prescribing practitioner or another practitioner who is responsible
for the care of the patient and authorized to write orders by
hospital policy, even if the order did not originate from him/her.
� CMS will re-evaluate in 5 years
� 482.24 (c)(1)(iii): Require all verbal orders to be authenticated
in accordance with specific timeframes defined in State or
Federal law, or within 48 hours. Silent about preempting State
law if State law is a broader specific timeframe.
20
New Proposed CMS-COP Rules
� Post Anesthesia Evaluation – 482.52 (b)(3)
� Current: Must be completed by the individual whoadministered the anesthesia
� Proposed: Post anesthesia evaluation report to bewritten by an individual qualified to administeranesthesia.
� Watch for these proposed rules to befinalized� Revise your Bylaws, Rules, and Regulations
accordingly
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EXHIBIT A
Successfully Reduce Delinquencies: Proven Techniques from the Trenches
21
HIM Department’s Rolein Timely Record Completion
22
Chicken-Egg
� All discharges/encounters must be received
� Analysis must be current
� Transcription must be current
� Access to the records by the physicians� Space and equipment
� Quiet
� Treats
� Restricting access by others
� Not there? Can’t be Completed.
� Continuous reporting of results
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Successfully Reduce Delinquencies: Proven Techniques from the Trenches
EXHIBIT A
23
Why Wait UntilDischarge?
Rush Copley Medical Center’s
Case Study
24
JCAHO TRACER METHODOLOGY
� JCAHO now looks at concurrent charts so
they must be accurate, timely & complete
at the point of care
� Reviewing records for deficiencies at the
point of care gets a jump start on the analysis
process and fewer items need to be flagged
post discharge, thus reducing the number
of delinquent charts
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EXHIBIT A
Successfully Reduce Delinquencies: Proven Techniques from the Trenches
25
Concurrent AnalysisImplementation Strategies� Leveraging the charting function
� Analysis
� Trainer
� Expanding e-Sig capability/functionality
� Involve the caregivers
� Compliance
� Provide them with adequate supplies
� Support the data collection and displaycomponent
26
Concurrent Analysis-Cons
� Apathy
� Time
� Labor
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Successfully Reduce Delinquencies: Proven Techniques from the Trenches
EXHIBIT A
27
Physicians and PhysicianExtenders ONLY
� Others employed to watch non-physicians
� Limits exposure to “What is a complete
record?”
28
Tips and Tools
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EXHIBIT A
Successfully Reduce Delinquencies: Proven Techniques from the Trenches
29
Utilize “Tools” Allowed
� CMS-COP: Alternative signature methods� 482.24 ������������� �� ������ �� ���� ���
������� ����� ��� ����� ���� �� ������� ���� ������ �������� �� ��� ��������� �������
� http://www.cms.hhs.gov/manuals/pub07pdf/AP-a.pdf pg. A-37
� JCAHO: Minimum signature requirements� IM.6.10
� H&P
� Operative Report
� Consultations
� Discharge Summary
32
How to Reel Them In
� HIM is NOT fun for Physicians
� Make it fun
� Awards-Oscars
� Food
� Location
� Prizes
� Be careful
� Hours of Access
30
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Successfully Reduce Delinquencies: Proven Techniques from the Trenches
EXHIBIT A
INT
ER
PR
ET
IVE
GU
IDE
LIN
ES
- H
OS
PIT
AL
S
TA
G
NU
MB
ER
RE
GU
LA
TIO
N
GU
IDA
NC
E T
O S
UR
VE
YO
RS
A1
02
(1
) A
ll e
ntr
ies
must
be
leg
ible
an
d c
om
ple
te,
and
must
be
auth
enti
cate
d a
nd
dat
ed p
rom
ptl
y
by
th
e p
erso
n (
iden
tifi
ed b
y n
ame
and
d
isci
pli
ne)
wh
o i
s re
spo
nsi
ble
fo
r o
rder
ing
, p
rov
idin
g,
or
eval
uat
ing
th
e se
rvic
e fu
rnis
hed
.
A1
03
(i
) T
he
auth
or
of
each
en
try
mu
st b
e id
enti
fied
an
d a
uth
enti
cate
his
or
her
en
try
.
A1
04
(i
i) A
uth
enti
cati
on
may
in
clu
de
sig
nat
ure
s,
wri
tten
in
itia
ls,
or
com
pu
ter
entr
y.
Inte
rpre
tiv
e G
uid
elin
es:
§4
82
.24
(c)(
1)
(1)
En
trie
s in
th
e m
edic
al r
eco
rd m
ay b
e m
ade
on
ly b
y i
nd
ivid
ual
s as
sp
ecif
ied
in
ho
spit
al a
nd
med
ical
st
aff
po
lici
es.
All
en
trie
s in
th
e m
edic
al r
ecord
must
be
dat
ed a
nd
au
then
tica
ted
, an
d a
met
ho
d
esta
bli
shed
to
id
enti
fy t
he
auth
or.
T
he
iden
tifi
cati
on
may
in
clu
de
wri
tten
sig
nat
ure
s, i
nit
ials
, co
mp
ute
r k
ey,
or
oth
er c
od
e.
When
ru
bb
er s
tam
ps
are
auth
ori
zed
, th
e in
div
idu
al w
ho
se s
ign
atu
re t
he
stam
p
rep
rese
nts
sh
all
pla
ce i
n t
he
adm
inis
trat
ive
off
ices
of
the
ho
spit
al a
sig
ned
sta
tem
ent
to t
he
effe
ct t
hat
h
e/sh
e is
th
e o
nly
on
e w
ho
has
th
e st
amp
an
d u
ses
it.
Th
ere
shal
l b
e n
o d
eleg
atio
n t
o a
no
ther
in
div
idu
al.
A l
ist
of
com
pu
ter
or
oth
er c
od
es a
nd
wri
tten
sig
nat
ure
s m
ust
be
read
ily
av
aila
ble
an
d
mai
nta
ined
un
der
ad
equ
ate
safe
gu
ard
s.
Th
ere
shal
l b
e sa
nct
ion
s fo
r im
pro
per
or
un
auth
ori
zed
use
of
stam
p,
co
mp
ute
r k
ey,
or
oth
er c
od
e si
gn
atu
res.
Th
e p
arts
of
the
med
ical
rec
ord
th
at a
re t
he
resp
on
sib
ilit
y o
f th
e p
hy
sici
an m
ust
be
auth
enti
cate
d b
y t
his
in
div
idu
al.
When
no
n-p
hy
sici
ans
hav
e b
een
ap
pro
ved
fo
r su
ch d
uti
es a
s ta
kin
g m
edic
al h
isto
ries
or
do
cum
enti
ng
asp
ects
of
ph
ysi
cian
ex
amin
atio
n,
such
in
form
atio
n s
hal
l b
e ap
pro
pri
atel
y a
uth
enti
cate
d
by
th
e re
spo
nsi
ble
ph
ysi
cian
.
An
y e
ntr
ies
in t
he
med
ical
rec
ord
by
ho
use
sta
ff o
r n
on
-ph
ysi
cian
s th
at
req
uir
e co
un
ter
sig
nin
g b
y s
up
erv
iso
ry o
r at
ten
din
g m
edic
al s
taff
mem
ber
s sh
all
be
def
ined
in
th
e m
edic
al s
taff
ru
les
and
reg
ula
tio
ns.
Th
ere
must
be
a sp
ecif
ic a
ctio
n b
y t
he
auth
or
to i
nd
icat
e th
at t
he
entr
y i
s, i
n f
act,
ver
ifie
d a
nd
acc
ura
te.
F
ailu
re t
o d
isap
pro
ve
an e
ntr
y w
ith
in a
sp
ecif
ic t
ime
per
iod
is
no
t ac
cep
tab
le a
s au
then
tica
tio
n.
An
y
syst
em t
hat
wo
uld
mee
t th
e au
then
tica
tio
n r
equ
irem
ents
are
as
foll
ow
s:
o
C
om
pu
teri
zed
sy
stem
s w
hic
h r
equ
ire
the
ph
ysi
cian
to
rev
iew
th
e d
ocu
men
t o
n-l
ine
and
in
dic
ate
that
it
has
bee
n a
pp
rov
ed b
y e
nte
rin
g a
co
mp
ute
r co
de.
o
A
sy
stem
in
wh
ich
th
e p
hy
sici
an s
ign
s o
ff a
gai
nst
a l
ist
of
entr
ies
wh
ich
must
be
ver
ifie
d i
n t
he
ind
ivid
ual
rec
ord
.
o
A
mai
l sy
stem
in
wh
ich
tra
nsc
rip
ts a
re s
ent
to t
he
ph
ysi
cian
fo
r re
vie
w,
then
he/
she
sig
ns
and
re
turn
s a
po
stca
rd i
den
tify
ing
th
e re
cord
an
d v
erif
yin
g t
hei
r ac
cura
cy.
A s
yst
em o
f au
to-a
uth
enti
cati
on
in
wh
ich
a p
hy
sici
an o
r o
ther
pra
ctit
ion
er a
uth
enti
cate
s a
rep
ort
bef
ore
tr
ansc
rip
tio
n i
s n
ot
con
sist
ent
wit
h t
hes
e re
qu
irem
ents
. T
her
e m
ust
be
a m
eth
od
of
det
erm
inin
g t
hat
th
e p
ract
itio
ner
did
, in
fac
t, a
uth
enti
cate
th
e d
ocu
men
t af
ter
it w
as t
ran
scri
bed
.
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EXHIBIT A
Successfully Reduce Delinquencies: Proven Techniques from the Trenches
INT
ER
PR
ET
IVE
GU
IDE
LIN
ES
- H
OS
PIT
AL
S
TA
G
NU
MB
ER
RE
GU
LA
TIO
N
GU
IDA
NC
E T
O S
UR
VE
YO
RS
Su
rvey
Pro
ced
ure
s: §
48
2.2
4(c
)(1
)
Ver
ify
th
at e
ntr
ies
are
auth
enti
cate
d;
Ver
ify
th
at t
he
dep
artm
ent
mai
nta
ins
a cu
rren
t li
st o
f au
then
tica
ted
sig
nat
ure
s, w
ritt
en i
nit
ials
, co
des
,
and
sta
mp
s w
hen
su
ch a
re u
sed
fo
r au
tho
rsh
ip i
den
tifi
cati
on
.
Ver
ify
th
at c
om
pu
ter
or
oth
er c
od
e si
gn
atu
res
are
auth
ori
zed
by
th
e h
osp
ital
's g
ov
ern
ing
bo
dy
an
d t
hat
a
list
of
thes
e co
des
is
mai
nta
ined
un
der
ad
equ
ate
safe
gu
ard
s b
y t
he
ho
spit
al a
dm
inis
trat
ion
. V
erif
y t
hat
th
e h
osp
ital
's p
oli
cies
an
d p
roce
du
res
pro
vid
e fo
r ap
pro
pri
ate
san
ctio
ns
for
un
auth
ori
zed
or
imp
rop
er
use
of
the
com
pu
ter
cod
es.
Ex
amin
e th
e h
osp
ital
's p
oli
cies
an
d p
roce
du
res
for
usi
ng
th
e sy
stem
, an
d d
eter
min
e if
do
cum
ents
are
b
ein
g a
uth
enti
cate
d a
fter
tra
nsc
rip
tio
n.
A1
05
(2
) A
ll r
eco
rds
mu
st d
ocu
men
t th
e fo
llo
win
g,
as a
pp
rop
riat
e.
A1
06
(i
) E
vid
ence
of
a p
hy
sica
l ex
amin
atio
n,
incl
ud
ing
a h
ealt
h h
isto
ry,
per
form
ed n
o m
ore
th
an 7
day
s p
rio
r to
ad
mis
sio
n o
r w
ith
in 4
8
ho
urs
aft
er a
dm
issi
on
.
A1
07
(i
i) A
dm
itti
ng
Dia
gn
osi
s
Su
rvey
Pro
ced
ure
s: §
48
2.2
4(c
)(2
)
Ver
ify
th
at t
he
pat
ien
t's m
edic
al r
eco
rd c
on
tain
s d
ocu
men
tati
on
of
a p
hy
sica
l ex
amin
atio
n p
erfo
rmed
w
ith
in t
he
req
uir
ed t
ime
per
iod
.
Ver
ify
th
at t
he
pat
ien
t re
cord
s co
nta
in t
he
foll
ow
ing
in
form
atio
n:
o
A
dm
itti
ng
dia
gn
osi
s;
o
C
on
sult
atio
n r
epo
rt d
ocu
men
ted
as
req
uir
ed b
y m
edic
al s
taff
po
licy
;
o
R
epo
rts
of
com
pli
cati
on
s, h
osp
ital
acq
uir
ed i
nfe
ctio
ns,
an
d u
nfa
vo
rab
le r
eact
ion
s to
dru
gs
and
an
esth
esia
;
o
P
rop
erly
ex
ecu
ted
co
nse
nt
form
s co
nta
inin
g a
t le
ast
the
foll
ow
ing
:
--
N
ame
of
pat
ien
t,
and
wh
en a
pp
rop
riat
e, p
atie
nt's
leg
al g
uar
dia
n;
--
N
ame
of
ho
spit
al
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Successfully Reduce Delinquencies: Proven Techniques from the Trenches
EXHIBIT A
33
Reduce Obstacles
� Get rid of stacks
� Use GOOD tags
� If EHR
� Build in edits to reduce analysis time/effort
� Establish queues
� Review the documentation requirements
� Revise/combine forms
� Combine Operative Worksheet and Post Op Progress Note
� Develop a form that has the Post-op Progress Note and the
components of the discharge summary (ambi-surg)
34
Give Them Information
� Delinquency Rate by Physician
� Incomplete Rate by Physician
� Good Guys List
� Get Close and Personal—to the Office
Manager
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EXHIBIT A
Successfully Reduce Delinquencies: Proven Techniques from the Trenches
35
Delinquency Profile
PROFILE FOR: Dr. D. Butcher CLINICAL SERVICE: Surgery
QUARTER: July-September, xxxx
Physician's Average Monthly Discharges: 12
Current Delinquencies: 2 as of 10/2/xxxx
Delinquency Percentage: 17%
Prior Quart Delinquency Percentage: 19%
Specialty Delinquency Percentage: 23%
Comparative Physician Group: 19% (inc. all specialties)
Number of Physicians in Comparative Group: 8
Tips: Visit HIM every Thursday. Did you know that you don't need to re-dictate your
history into your discharge summary? Dictate to the transcriptionist to pick up the
history and we'll insert that piece for you. Look for tags on the records while on the
floor. It may save you a trip to HIM. Have you signed up for electronic signature
yet? It, too, may save you a trip to HIM. Thursday is chocolate day in HIM. Call
x254 to have your records pulled in advance of your visit. Thanks.
36
When the Carrot Doesn’t Work
� Suspension
� Revise Rules to suspend at 21 days but still
leave the definition of delinquency as 30 days
� See Lutz article for sample policy
� Monetary Penalties
� Fines
� Non-Monetary Penalties
� Special privileges
� Additional Assignments
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Successfully Reduce Delinquencies: Proven Techniques from the Trenches
EXHIBIT A
37
Getting Administrative Support
� Reimbursement
� Coding
� Denials
� Oryx/CMS abstracting
� CMS—Part A
� Qui Tam
� CMS—Part B� Documentation doesn’t support billing
� Labor time/space
38
References/Resources
� Conditions of Participation: http://www.access.gpo.gov/nara/cfr/waisidx_99/42cfr482_99.html
� Dunn, Rose. More with Less. HcPro publications
2004
� Federal Register. March 25, 2005 p. 15266-15274
� Flanagan, Christopher. “Using ‘Key Indicators’ to
Report, Monitor, and Improve HIM Operations”
AHIMA BOK
� Lutz, Laurie. “Physician Record Completion Policy.”
AHIMA BOK
References/Resources
� Conditions of Participation: http://www.access.gpo.gov/nara/cfr/waisidx_99/42cfr482_99.html
� Dunn, Rose. More with Less. HcPro publications2004
� Federal Register. March 25, 2005 p. 15266-15274� Flanagan, Christopher. “Using ‘Key Indicators’ to
Report, Monitor, and Improve HIM Operations”AHIMA BOK
� Lutz, Laurie. “Physician Record Completion Policy.”AHIMA BOK
� http://www.dwt.com/practc/healthcr/bulletins/04-05_CMSCoP(print).htm#a1
38
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Exhibit B
Operative Record document
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23Successfully Reduce Delinquencies: Proven Techniques from the Trenches
EXHIBIT B
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Exhibit C
Excerpt from More with Less: Best Practices for HIM Directors by Rose T. Dunn, RHIA, CPA, FACHE, publishedby HCPro, Inc., 2004
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25Successfully Reduce Delinquencies: Proven Techniques from the Trenches
EXHIBIT C
Not all incomplete patient records are due to a lack of dictated or signed reports. Some require
completion of documents, signing/cosigning of progress notes, and the HIM department favorite,
verbal/telephone orders. For a busy physician or revered “high admitter,” the number of incomplete
records can grow quickly. One physician said incomplete records seem to breed overnight.
With physician reimbursement declining, regulations increasing, and paperwork quadrupling, it’s no
wonder physicians miss documents and have incomplete records. This chapter focuses on helping
doctors—which simultaneously benefits the HIM department—and completing records at or near the
time of discharge.
Concurrent record analysis
Organizations have used several methods to achieve record completion while patients are in house.
Some of the following options are equally as effective in active outpatient settings where patients
have multiple encounters or rehabilitative settings:
• Concurrent record analysis occurs during concurrent record review by the record-review team
- Plus: The reviewers are already looking at the documentation and at this time they can
It has been said there are no incomplete or delinquent medical records in veterinaryhospitals—a theory that makes us think about the adequacy of documentation of ahuman’s health compared to our pets. We allow records to be completed after thepatient is long gone, yet expect physicians to remember intricate details of the careprovided.
INCOMPLETE MEDICAL RECORDS
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EXHIBIT C
26 Successfully Reduce Delinquencies: Proven Techniques from the Trenches
assess whether the documentation is truly complete and adequate for other
caregivers.
- Minus: Depending on the review approach taken, not all records may be reviewed.
These reviewers, typically clinicians, may find the tagging of incomplete documenta-
tion more appropriate for clerical staff.
• Concurrent record analysis occurs during utilization and case-management reviews by staff who perform
these functions
- Plus: These individuals are most in need of complete documentation and have the
ability to encourage additional details often missing from physician documentation.
- Minus: Depending on the utilization review/case-management approach, not all
records may be reviewed. These reviewers may find tagging incomplete documenta-
tion more appropriate for clerical staff.
• Patient-care personnel identify documentation deficiencies and tag them as they compile the patient record
- Plus: The patient-care support staff or unit secretaries are in and out of all patient rec-
ords on the floor and can see whether a document has blanks or a verbal or telephone
order lacks a physician signature. Tagging this deficiency is within their skill set. These
staff are more likely to see the physician and remind him or her to complete the record.
- Minus: Many organizations have decreased the support staffing in patient-care areas.
Since many reports are now distributed through a network printing system, support staff
have absorbed much of the charting efforts performed by HIM and ancillary services.
• Designated HIM staff are assigned to review patient records daily for documentation deficiencies and tag
them accordingly
-Plus: The HIM staff’s purpose is to complete records, and therefore, they believe tag-
ging is an appropriate assignment.
-Minus: The HIM staff will not have the opportunity to remind physicians because the
presence of HIM staff in any patient-care area will be transient.
A coder’s true colors
Some physicians prefer a certain color; they are more aware of the flag color and more willing to
respond to the notice. If there is a large medical staff, there may not be enough colors, so segregate
color assignment by clinical specialty to avoid the possibility of overlapping physicians with the same
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27Successfully Reduce Delinquencies: Proven Techniques from the Trenches
EXHIBIT C
color tag serving patients on the same floor. However, if the organization is unable to designate single
colors to each physician or is unwilling to permanently assign HIM staff to the patient-care area, then
the having patient-care staff review records may be the best choice because tagging alone is often not
enough to encourage a physician to complete a document. With all the other issues physicians deal
with, they often need someone to point to an item or remind them to sign a document.
Timely record processing
Reducing delinquent records is partially dependent upon a physician’s access to the records. If the
HIM processing effort consumes too many of the days between discharge and delinquency, the physi-
cians will have a restricted period in which to complete the record. Physicians may react by pointing
fingers at HIM inefficiencies. Demonstrate to the physicians that the records are available shortly after
discharge for their access and completion.
Timely transcription
In the past, some organizations allowed discharge summaries to fall to the lowest priority in the tran-
scription queue. However, this report assists the physician’s office most in continuity of care. This
report is also key for some coding activities. Convincing physicians to dictate at discharge requires a
quid pro quo exchange—a guarantee that they will have the office copy filed in their office record by
the time they see the patient for follow-up, often three to five days later. Improving the timeliness of
transcription for all reports is imperative to gaining the physician’s conviction for dictating promptly
after surgery, consultations, and discharge. HIM managers must recognize that achieving this level of
customer satisfaction may result in an increase in dictation and the associated cost of transcription.
Facilitating dictation
Add hands-free dictation capability to locations where physicians may dictate (e.g., the operating
room, emergency department (ED) examination rooms, procedure rooms). Another option is to use
downloadable, portable units to encourage physicians to dictate in the building.
Scribes
Scribes and other physician extenders can support the HIM department in timely record completion.
Scribes often are conscientious and will respond to an HIM request to come in to dictate or complete
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EXHIBIT C
28 Successfully Reduce Delinquencies: Proven Techniques from the Trenches
documentation. These individuals also are invaluable resources in identifying redundant documenta-
tion requirements as well as assisting coding in obtaining further clarification of a treated condition.
Building rapport with physician extenders will benefit HIM in multiple ways. You can ensure that
these individuals are not inappropriately using signature stamps and that final authentication must
be made by the physician. Some physicians become so trusting of their scribes or extenders that they
do not hesitate to loan their signature stamp. Federal and most state laws prohibit use of the signa-
ture stamp by anyone other than the physician.
Forms redesign
Anyone who has converted to an electronic medical record or transitioned to an electronic forms-man-
agement system knows that a total forms-redesign project is probably one of the most time-consuming
projects a HIM manager will encounter. The involvement of many who believe they have proprietary
rights to forms adds another dimension to the challenge. Tying documentation fields on the various
forms to state, federal, and JCAHO requirements, as well as departmental or leadership requires
attention to detail. However, any streamlining, elimination of redundant documentation, and refor-
matting that facilitates completion will be overwhelmingly welcomed by all users, including the
physicians. These projects often provide the following benefits:
• Reduce the number of forms
• Standardize the location of common fields (i.e., where the patient name and ID informa-
tion will appear)
• Eliminate outdated documentation efforts
• Implement the use of common terminology
• Impact positively on incomplete records
• Save the organization in forms inventory
Reassessing documentation requirements
As new documentation expectations surface, medical staffs scurry to update their rules and regulations.
Unfortunately, we rarely visit the entire set of rules to determine whether anything has fallen by the way-
side. This full review effort does not need to be an annual event, but triennially is not unreasonable.
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29Successfully Reduce Delinquencies: Proven Techniques from the Trenches
EXHIBIT C
For example, the Conditions of Participation Interpretive Guidelines for 482.24 allow a single sign-off of multi-
ple entries (see Figure 5.1). Although the JCAHO requires certain individually signed documents, the
use of the two regulations in combination may reduce some efforts for your medical staff. Another
benefit is that it provides an opportunity for the medical staff to be reeducated about documentation
requirements.
Providing comparative data for physicians
Physicians thrive on data. They analyze and digest it. As with most individuals, they seek to have their
personal data surface as the “best.” If the data are to be presented, they must be credible and unbi-
ased to scientists. Developing a profile (see Figure 5.2) reflecting data elements that require minimal
effort include:
1. Physician’s name.
2. Specialty.
3. Average monthly discharges.
4. Current delinquencies (based on either a daily or weekly report).
5. Delinquency percentage as a percent of average monthly discharges (delinquencies divid-
ed by average monthly discharges for that physician).
6. Compared to others in same specialty, delinquency rate for the physician compared to
those for all physicians in the same specialty who had discharges).
Authentication definedFigure 5.1
482.24—Authentication:
“A system in which the physician signs off against a list of entries which must be verified in the
individual record.”
www.cms.hhs.gov/manuals/pub07pdf/AP-a.pdf p. A-37
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EXHIBIT C
30 Successfully Reduce Delinquencies: Proven Techniques from the Trenches
7. Compared to others with similar average discharges. This one may be more difficult to cal-
culate depending on the size of the medical staff as one will need to examine all the
physicians on staff with comparable monthly discharges; use a spreadsheet application to
sort data. The comparable monthly discharges should be a range of no more than +/-10%.
Make the HIM department a great place to visit
Build it and they will come. Establish a friendly environment where the physicians can find refuge—
coupled with timely processing—to control incomplete records. Patient care is not without stress, and
a place to calm down is appealing to any physician.
Sample physician delinquency assessmentFigure 5.2
Profile for: Dr. D. Butcher Clinical service: Surgery
Quarter: July–September
Physician’s average monthly discharges: 12
Current delinquencies: 2 as of 10/2/xxxx
Delinquency percentage: 17%
Prior quarter delinquency percentage: 19%
Specialty delinquency percentage: 23%
Comparative physician group: 19% (includes all specialties)
Number of physicians in comparative group: 8
Tips:
• Visit HIM every Thursday.
• Did you know you don’t need to redictate your history into your discharge summary?
Dictate to transcription to pick up the history, and we’ll insert that piece for you.
• Look for tags on the records while on the floor. It may save you a trip to HIM.
• Have you signed up for electronic signature yet? It may save you a trip to HIM.
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31Successfully Reduce Delinquencies: Proven Techniques from the Trenches
EXHIBIT C
Consider the following options:
• Stock up on readily accessible beverages (e.g., coffee, soda, juice)
• Supply a small bowl of snacks or candy
• Hold periodic raffles for physicians who
- routinely stop by to check on their records
- rarely or never have delinquent records
- have the lowest delinquency rate in their specialty/comparative group
Sticks
Up until now, we have been discussing carrot-type approaches. The last option is the stick approach.
The stick surfaces in a variety of measures that organizations have had to institute. Common
approaches include suspensions and fines. Suspension often inconveniences the patient more than
the physician. Fines, however, have been found to be effective. Neither of these sticks works for those
physicians who neither admit nor schedule surgery. However, a measure that does work effectively for
nonadmitting physicians such as anesthesiologists, hospitalists, and ED physicians is an incentive
plan for no delinquencies (see Figure 5.3).
As with any penalty system, consistency of enforcement is paramount. Administration and the med-
ical staff must support the sanctions regardless of the physician involved. On the other hand, if there
is a shade of doubt about whether the penalty should be applied—perhaps due to HIM staff failing to
pull all records or a delay in charting transcription—then the penalty should not be invoked.
Residents/interns
Those of you working in a teaching facility have an additional hurdle to record completion: residents
and interns. Although they contribute a lot of documentation to the patient’s record, and it is usually
legible, they also leave documentation voids. These individuals are similar to extenders in that they will
create some of the documentation for the attending physician. However, because they are not employed
by the physician, their loyalty to doing all of what is asked of them is not always forthcoming.
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EXHIBIT C
32 Successfully Reduce Delinquencies: Proven Techniques from the Trenches
The first rule that must be added to your medical staff rules is that attending physicians are responsi-
ble for patients’ record completion. If the resident leaves an undictated discharge summary, then the
attending or sponsoring physician, is responsible for preparing the discharge summary.
Approach Suspensions Fines Incentives
Common
premise
Failure to complete records within 30
days of discharge results in
suspension of admitting and
operating privileges. Scheduling
services is prohibited except in life-
threatening situations.
Failure to complete records
within 30 days of discharge
results in the levy of a fine
payable by the physician to a
fund (education, HIM, charitable,
etc.).
Failure to complete records
within 30 days of discharge
results in loss of an incentive
payment that may be as much as
$5,000 or a reduction in the
contracted payment to the
nonadmitting group of the same
amount.
Major stick Failure to complete the records within
a certain period after being notified of
suspension could result in loss of
medical staff membership.
Failure to pay the fine within a
certain period after being
notified of the levy could result in
loss of medical staff
membership.
Loss of contract.
Impact Physician frustration; some projection
to clerical and management staff in
HIM. If scheduling is prohibited or
services cancelled, the patient is
inconvenienced by a delay or change
of hospital.
Sometimes, the fines are paid,
but the records remain
incomplete for some time
thereafter. The patient is not
inconvenienced.
Contract cancellation results in
an inconvenience for hospital
management and may disrupt
members of the medical staff
who respect and have aligned
with the nonadmitting group.
Other Occasionally, members of the same
group had their privileges suspended.
If not implemented for all
nonphysician groups, may result
in animosity.
Incentive plan for reducing delinquenciesFigure 5.3
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33Successfully Reduce Delinquencies: Proven Techniques from the Trenches
EXHIBIT C
Counting incompletes and delinquents
HIM professionals know there is no wiggle room in determining which record has achieved “must-do”
status, or as some may label it, delinquent. Depending on state law, this period could be as short as
15 days after discharge or, by federal statute (Conditions of Participation), 30 days. When it comes to
sticks, the state and federal governments’ leaves JCAHO’s stick in the shadows.
Use some of the above approaches to encourage physicians to visit the HIM department more fre-
quently and avoid being suspended or labeled as delinquent. However, if you wait until day 30, for
example, to notify the physician or take action on this record, then there is no chance that this record
will be completed within the time frame mandated by the regulations.
Steps to simplify resident/attending physician coexistenceFigure 5.4
1. Always provide a bowl of snacks for the residents; an occasional sandwich assortment is
even more enticing
2. Establish a reporting system that alerts the attending and chief resident of any upcoming
delinquent records
3. Require the attending physician to sign off on the resident’s evaluation form
4. Suspend the chief resident or chief of service if the residents allow records to become
delinquent
5. Contribute $100 each month that there are no delinquent records for residents to that
service’s education fund
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EXHIBIT C
34 Successfully Reduce Delinquencies: Proven Techniques from the Trenches
Capturing deficiencies for nonphysicians
If your organization is required to analyze records for documentation deficiencies for nonphysicians,
then the organization must make a conscious and documented decision whether to count these cases
in the incomplete and delinquent count. If the organization states that a record is not complete, for
example, until the ED nurse records the discharge condition and that element is incomplete, then the
record is technically incomplete. The challenge arises when this the agency nurse does not return for
weeks, months, or forever. Further, what is the penalty for failure to complete the record if the nurse
is gone?
Many organizations have adopted the policy that nonphysician documentation is to be managed by the
employed leadership of that area. In this example, it would be the ED manager. The ED manager
should have established appropriate processes and performance-improvement measures to capture
the required documentation by the time the patient leaves the area or the nurse’s shift changes.
1. Ensure your incomplete tracking system is counting days from date of discharge—not the date thatit was analyzed or logged into the department.
2. Establish a weekly notification process for the physicians that keep them informed about therecords requiring their attention.
3. If suspensions occur, initiate the suspension seven days in advance of the absolute “drop-dead”date for the record to be in violation of state or federal law. This might be day 21 in a state thatrequires all records to be completed within 30 days of discharge.
4. Use the maximum period as the definition of “delinquency” to provide you with the greatest flexi-bility with JCAHO.
TIPS
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35Successfully Reduce Delinquencies: Proven Techniques from the Trenches
EXHIBIT C
Building dialogue with physicians
Interview physicians regularly, either on the patient-care floors, during medical staff meetings, or
while they are doing their records in your department to gain input into improving this process.
During one assessment, we found the only dictation unit in the labor and delivery area was in the
fathers’ waiting room. The surgeons did not think it was appropriate to dictate their reports there.
Why was the dictation unit installed there? Due to a renovation, the surgeon’s charting area became
the fathers’ waiting room. No one told HIM that the renovation occurred. Another interview session
suggested that the record-completion area have a small copier so the physician could copy progress
notes and take them to office billing staff. The physicians stopped by several days a week to copy.
While there, they completed their notes. Sure seemed like a waste of professional time seeing physi-
cians copying their records, but it was an inducement for some physicians.
Summary
Timely completion of patient records requires the following tasks:
• Timely identification of those records needing attention
• Timely transcription of reports to encourage physicians to dictate immediately
after service
• Ensuring unnecessary documentation requirements are reduced/eliminated
• Providing physicians and others with the tools needed, wherever necessary, to complete
the records
• Improving forms’ design to allow easy recognition of those fields requiring attention by
the physician, nurse, other clinicians
• Accurately counting records as incomplete/delinquent
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EXHIBIT C
36 Successfully Reduce Delinquencies: Proven Techniques from the Trenches
• Establishing an inviting environment that encourages frequent visits to the physicians
incomplete area
• Consistently enforcing rules that apply to all who must complete records
There are several methods to achieve records completion while patients are in house and some are
equally effective in active outpatient settings. Improving the timeliness of transcription of all reports
may result in more timely dictation of reports by physicians, as well as an increase in the type and
volume of reports dictated by physicians. Adding scribes or other physician extenders to assist physi-
cians may improve both the quality and timeliness of documentation. Develop a profile that a physi-
cian can use to compare his or her performance to other physicians in the organization. As your staff
identify traits of physicians who never fall into the delinquent zone, list those as tips on the profile.
Offer both carrots and sticks. Reward physicians who religiously complete records. Consider penalties
for those who procrastinate, regardless of the tools offered to assist them. Finally, remember to com-
municate with the physicians to build rapport and recognition for the many challenges faced by HIM.
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Exhibit D
Articles taken from HCPro’s monthly newsletter Medical Records Briefing
- AL hospital turns around delinquent record rateCommunication, revised rules, facilitywide effort all help with dramatic reduction(April 2005)
- Delinquent records trouble spotSurvey shows 9% cited by JCAHO in this area(February 2005)
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EXHIBIT D
38 Successfully Reduce Delinquencies: Proven Techniques from the Trenches
www.hcpro.com
Between January 2003 and October 2004, the delin-quent record rate at Carraway Methodist MedicalCenter (CMMC) in Birmingham, AL, decreased all theway from 52% to 1%.
The facility received a recommendation for improve-ment from the JCAHO during its March 2004 surveybecause it lacked a compliant 12-month track record,says Pamela Burns, RHIT, CCS, HIM director.
“Our quarterly statistics never exceeded 50% of ouraverage quarterly discharges, but there were a fewindividual months that exceeded 50% in the earlypart of 2003.”
Thanks to intense education during JCAHO prepsessions, the hospital saw the delinquent record ratestart to decline by survey time.
Communicate, communicate, communicateThe JCAHO task force at CMMC identified the delin-quent chart count as an area that needed attention.
“Everybody had to get on the same page, and theonly way we could do that was to communicate,communicate, and communicate some more,” Burnssays.
For that reason, the delinquent chart count made itonto every committee meeting’s agenda and ap-peared during all managers’ meetings, presentationsfrom the quality improvement director, and Burns’presentations to medical staff committees. The hospi-tal’s quarterly newsletter reported progress to theentire staff and gave kudos to the medical staff fortheir progress and hard work.
Administration’s involvement was imperative, Burnssays. Chief Financial Officer Peggy Allen champion-ed the project. Allen and Burns’ second in commandmet weekly to discuss the chart count.
Burns also sent weekly notifications to physicians viamail and fax and mailed weekly reports of deficien-
cies to each physician to make them aware of whatcharts remained incomplete.
“It was imperative that this process be consistent andthat the notifications were timely,” Burns says.
Physicians revise rules To help with consistency, CMMC revised medicalstaff rules and regulations outlining a timetable forchart completion. One revision required chart com-pletion within 21 days from discharge, rather than30 days.
With the new system, the medical staff had to followthe new rules they approved. Information technolo-gy staff produced reports that listed each physician,the number of incomplete charts, and the number ofdelinquent charts broken down by the number ofdays from discharge the record had aged (i.e., <21days, <28 days, <35 days).
AL hospital turns around delinquent record rate Communication, revised rules, facilitywide effort all help with dramatic reduction
Three reasons for delinquent records
Pamela Burns, RHIT, CCS, HIM director ofCarraway Methodist Medical Center inBirmingham, AL, cites the following three rea-sons for her facility’s high delinquent recordrate:
1. Lack of persistent, effective communication,and/or notifications to the medical and residentstaff from the HIM department.
2. Poor rules and regulations that allowed achart to age to 51 days post-discharge beforesuspension of a physician’s privileges. Thephysician was suspended after receiving consis-tent notifications.
3. Inclusion of only inpatient charts when calcu-
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39Successfully Reduce Delinquencies: Proven Techniques from the Trenches
EXHIBIT D
www.hcpro.com
The new medical staff rules included three levels ofnotification each week, depending on the chart’sage. For charts older than 21 days, physiciansreceived a letter from Burns. Charts older than 28days warranted a notification from the chief of themedical staff. Physicians received a notification fromthe CEO of relinquishment of medical staff privi-leges for charts more than 35 days old.
The information services department provided thereports and abstracted the numbers onto a spread-sheet to allow notifications to be automatically gen-erated and sent through mail merge.
The HIM analysis staff and physician workroomstaff were dedicated to their roles in the process,Burns says. The analysis team provided the work-room with charts within fivedays post-discharge. Theworkroom staff called officemanagers, beeped physicians,faxed/mailed deficiency lists,and stopped residents in thehallways.
“You name it, they’ve done it,”Burns says.
Eliminate surprisesTo assist with the chart countcompletion process, Burnsand the rest of the team atCMMC included every deficiency at the initialanalysis process.
For example, for a discharge summary awaiting dic-tation, staff wrote, “Dictate discharge summary,awaiting transcription and signature for dischargesummary.” That eliminated surprises for the physicians.
Once the physician dictated, the dictation deficiencywas cleared. As each step was completed, the sys-tem updated the record’s status.
This benefited the weekly chart counts because thedeficiency note for the attending’s signature wasseparate from the deficiency note for transcription.
This alerted providers of a recent dictation or that aresident was responsible for that dictation, ratherthan the attending physician. This also preventedunnecessary reminders to attending physicians responsible for any delays. In the alphabetical listingof physician deficiencies, if a resident was assignedto a dictation, the computer grouped the resident toreport the page before the attending’s name.
Stay on top of transcriptionBurns also found daily log sheets of pending tran-scription needs helpful. “If you have an outsourcedcompany providing your transcription needs, reviewthe contract and make sure that the turnaround timeframes for your discharge summaries are no longerthan 48 hours,” she says. If that’s in your contract,then the vendor has to provide the manpower to
make it happen.
If your transcription doesn’tturn around quickly, thatdelays the workroom processesand, in turn, delays physicians’ability to fulfill their responsi-bilities. This same scenarioapplies to in-house transcrip-tion as well.
“Adequate coverage is impera-tive,” she says.
Another change that affectedthe delinquent record rate was including observa-tions, ambulatory surgery, outpatient endoscopy,and other outpatient cases as of January 2004.
“If we were going to conduct a full analysis processof the chart, we needed to be counting all the charts,”Burns says. With an average of only four or five delin-quent outpatient charts per week, adding those casesto the total monthly number helped reduce the overallrate.
Hard-earned but worth itCMMC’s delinquent record project met initial resis-tance, Burns says. “Not everyone was on the samepage. Communication and commitment were key.”It wasn’t an easy task, but eventually Burns and her
Reducing the time allowed to complete the medical
record and, at the same time,providing weekly reminders
of chart deficiencies led to allinvolved becoming sensitizedto completing their charts.
—Kimball I. Maull, MD
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EXHIBIT D
40 Successfully Reduce Delinquencies: Proven Techniques from the Trenches
Burns and her team won over the medical staff.
In fact, the hospital service committee chair, Kimball I. Maull, MD, says “the improved efficien-cy in chart completion has been a source of greatpride within the Carraway organization. Reducingthe time allowed to complete the medical recordand, at the same time, providing weekly remindersof chart deficiencies led to all involved becomingsensitized to completing their charts.”
This project’s success has not only improved chartcompletion for statistical purposes, but it affectedthe turnaround time for release of information pur-poses, coding, and overall quicker availability of acomplete record for continuity of care, Burns says.
“The delinquent record status must be on the radarscreen weekly for success to be achieved and main-tained,” she says.
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41Successfully Reduce Delinquencies: Proven Techniques from the Trenches
EXHIBIT D
Editor’s note: Survey results are based on 306responses from the following categories:
• Small (fewer than 150 beds)—55%
• Medium (150–300 beds)—27%
• Large (more than 300 beds)—18%
Forty-four percent of respondents to the recent MRBbenchmarking survey on delinquent records main-tain a delinquency level of 10% or less. Another 23%have a rate of 25% or higher (see Fig. 1).
Veteran HIM professional and JCAHO expert Jean S.Clark, RHIA, service line director of HIM at RoperSt. Francis Healthcare in Charleston, SC, expressedsurprise and disappointment at those numbers. “Thisis a requirement that has been around for a longtime, and it would seem we would be doing betterat it,” she says.
Clark is not the only one discouraged by the results.More than half of respondents (60%) said they areeither “very satisfied” or “satisfied” with their de-linquent record rates, but another 31% are either“dissatisfied” or “very dissatisfied” with them (seeFig. 2).
“I am glad to see that a large number are not happywith their delinquent records, since timely, accurate,and complete documentation is a key to qualitypatient care and safety,” Clark says. “It means wehave to continue to push to get doctors and admin-istration behind this effort.”
JCAHO citations aboundAnother statistic that does not impress Clark is thatthe JCAHO cited nearly one in 10 survey respon-dents for delinquent records.
“I think 9% of hospitals receiving JCAHO recommen-dations in this area is high,” she says. The patienttracer survey process makes the record at the pointof care an important tool for surveyors. “If 9% ofhospitals are still having trouble [completing records]
after discharge, it makes me concerned for the suc-cess of their overall survey.”
And the JCAHO requirement to conduct an annualperiodic performance review should force you toidentify areas vulnerable to documentation deficien-cies, Clark says. “A focused review and plan ofaction should help to improve documentation beforethe records come to the HIM department.” Andimproving documentation is key if you have troublewith record completion, because once records get tothe HIM department, staff there can only help youget signatures on discharge summaries.
Administrative support a mustThe administration at Straith Hospital for SpecialSurgery in Southfield, MI, has taken a special interestin the delinquent record rate, making it easier forGloria Kendrick, RHIA, health information manag-er, and her staff to keep the rate at less than 5%.
“Without their backup, the only other way I ameffective at keeping the chart delinquencies low isby establishing a relationship of mutual respect withthe physicians,” she says. “They understand that Ilook out for them in reviewing their records for legalinconsistencies, and they are eager to assist me withmy charting issues.”
But some HIM directors achieve low delinquencyrates only after their administration receives a slapon the wrist from the JCAHO, says Rose T. Dunn,RHIA, CPA, FACHE, FHFMA, chief operating officerof First Class Solutions in St. Louis. “They are luckythat CMS or the state didn’t walk in and put theirlicensure in jeopardy. CMS has a much bigger stickthan JCAHO.”
Low delinquency takes timeWhen asked how much time facilities spend ondelinquent records, 14% of respondents said “noneof the time” or “little of the time.” About half (54%)said they spend “some of the time” and the remain-ing 32% said they spend “most of the time” or “all ofthe time.”
Delinquent records trouble spot Survey shows 9% cited by JCAHO in this area
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EXHIBIT D
42 Successfully Reduce Delinquencies: Proven Techniques from the Trenches
One respondent said that delinquent records costher facility 2.5 full-time equivalent employees, or$60,000, per year. But Clark is not surprised at thepercentage of time it takes to deal with the process.
“It can be very time consuming, especially depend-ing on how often the hospital conducts its delin-quent counts,” she says.
Despite the time it may cost you and your depart-ment, HIM has several responsibilities that affect thedelinquent record rate, Dunn says. These include thefollowing:• Regularly notifying physicians of their incomplete
and delinquent records• Processing discharged records in a timely manner
so physicians get the records promptly after dis-charge, when information is fresh in their minds
• Consistently applying the rule for all physicians
Making the HIM department a fun environment forthe physicians is always a good way to get them tocome and complete their records, Dunn adds. Youshould make the physicians’ work area as comfort-able and appealing as possible.
Fig. 2: How satisfied are you with your delinquentrecord rate?
Fig. 1: What is your delinquent record rate?
29% very satisfied
satisfied
neutral
dissatisfied
very dissatisfied
31%
9%
23%
8%
Editor’s note: Survey results are based on 306responses from the following categories:
• Small (fewer than 150 beds)—55%
• Medium (150–300 beds)—27%
• Large (more than 300 beds)—18%
Forty-four percent of respondents to the recentMRB benchmarking survey on delinquent recordsmaintain a delinquency level of 10% or less.Another 23% have a rate of 25% or higher (seeFig. 1).
Veteran HIM professional and JCAHO expert JeanS. Clark, RHIA, service line director of HIM atRoper St. Francis Healthcare in Charleston, SC,expressed surprise and disappointment at thosenumbers. “This is a requirement that has beenaround for a long time, and it would seem wewould be doing better at it,” she says.
Clark is not the only one discouraged by theresults. More than half of respondents (60%) saidthey are either “very satisfied” or “satisfied” withtheir delinquent record rates, but another 31% areeither “dissatisfied” or “very dissatisfied” with them(see Fig. 2).
“I am glad to see that a large number are nothappy with their delinquent records, since timely,accurate, and complete documentation is a key to
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Resources
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RESOURCES
44 Successfully Reduce Delinquencies: Proven Techniques from the Trenches
Speaker resources
Rose T. Dunn, RHIA, CPA, FACHEFirst Class Solutions, Inc.2060 Concourse DriveSt. Louis, MO 63146Phone: 314-997-8998Fax: 314-997-0400E-mail: [email protected]
Eileen M. O’Heron, RHIADirector Medical RecordsRush-Copley Medical Center2000 Ogden AvenueAurora, IL 60504Phone: 630-499-2304Fax: 630-236-4279E-mail: [email protected]
HCPro sites
HCPro: www.hcpro.com
With more than 17 years of experience, HCPro, Inc., is a leading provider of integrated information, educa-tion, training, and consulting products and services in the vital areas of healthcare regulation and compliance.The company’s mission is to meet the specialized informational, advisory, and educational needs of thehealthcare industry and to learn from and respond to our customers with services that meet or exceed thequality they expect.
Visit HCPro’s Web site and take advantage of our online resources. At hcpro.com you’ll find the latest newsand tips in the areas of
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45Successfully Reduce Delinquencies: Proven Techniques from the Trenches
RESOURCES
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HCPro offers the news and tips you need at the touch of a button—sign up for our informative FREE e-mailnewsletters, check out our in-depth, how-to information in our premium newsletters, and get advice from ourknowledgeable experts.
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