Lessons learned from the medical records department at a hospital

Some best practices for billing and coding a medical record have been the same for many years. This is apparent when I look back on the two years when I was in college and worked in the medical records department of a local hospital. My job as a part-time, evening employee was to take any paper records that had not made it into a patient’s chart and make certain the documents were added to the giant chart — wherever in the hospital chart it might be — and place those documents in the correct place (everything had a place and a tab to mark it).

After patients were discharged, those giant folders full of all the patient reports documenting the hospital stay (tests done, orders given, test results, doctor’s interpretation of the tests, nurses orders, informed consents and more) were delivered to the medical records department for their next journey. Stacks of charts lined the walls of our department most of the time. For someone like me, who loves completing a task, it was very disturbing that the stacks never seemed to go away. The business of the hospital never stopped.

MEDICAL RECORDS PROTOCOL

There were three employees in my medical records department who essentially ensured the hospital was reimbursed for its services. These three employees spent their days combing through charts first, putting all the paperwork in order, so they could easily find all orders made, tests done, tests completed and test reports written and signed by the doctors. If any of the required signatures or reports were not completed by the doctor, the chart would go on a shelf with that doctor’s name on it, and the doctor would be sent an inter-office memo (no texting or email back then) letting them know they needed to finish their charts.

The coders would flag all the documents in the correct places and wait for the required documentation from the doctor before they billed anything to insurance. If the doctor procrastinated, the coders would notify the doctors that they could have their hospital privileges suspended. (It didn’t take me long to figure out why most of the doctors who came in to work on charts were in a bad mood.)

NOTHING IS BILLABLE UNTIL IT’S DOCUMENTED

What struck me about this system — nothing was billable until it’s documentation was complete. We had specific steps and protocols we followed to be certain the hospital paid for all tests done and that it would also be able to keep the money if and when an audit occurred.

A few of the lessons I’ve carried forward with me:

1. Take care of your employees, and they will take care of your patients and you.
2. Create protocols and processes for every detail in the practice, and you will be profitable and stay out of trouble.
3. Have a check and balance system to be certain you don’t miss anything.
4. Don’t bill for anything that is not first documented correctly.
5. Educate your team on the why of your protocol and process, so they embrace it — not fight it.
6. Continue to review your processes, and correct them when and where needed.

MEDICAL RECORDS, LARGELY, REMAIN THE SAME

A lot has remained the same in medical records. Diligence, patience and attention to detail cannot be overlooked. And it is important that all of the team are a part of the process. OM

Find more coding tips on p.29, “Consider Outsourcing Billing Services.”

DR. JASPER practices in West Palm Beach, Fla.. She is an American Academy of Optometry fellow and is chief optometric editor of Optometric Management. Email her at april.jasper@pentavisionmedia.com.