COMPLIANCE WITH HCFA TERMINOLOGY; AN AUTOMATED SYSTEM FOR AUDIT OF ANESTHESIA DOCUMENTATION

Abstract

S27 INTRODUCTION: Automated Anesthesia Record Keepers (AARK) provide a method of tracking compliance with Health Care Finance Administration (HCFA) required documentation. Documentation needs to be 100% complete and manual audit of charts is both tedious and expensive for support staff to perform. The Duke anesthesia information group developed a database analysis program designed to ensure both the completeness of the anesthesia record as well as 100% compliance with HCFA documentation. These notes detailed the presence and participation of the attending anesthesiologist, and staff, in those elements of each case and ancillary medical service as mandated by HCFA. METHODS: A prospective before and after comparison study was performed at a tertiary care medical center [1]. Documentation was assessed using our program before Documentation Guidelines (BDG) were instituted, after DG were suggested to Faculty as to what terms should be included in the record (ADG), and for three consecutive months 6 months after a $5.00 per complete record remuneration was started (AR1-3) [Months 1 through 3]. All incomplete records were returned to staff for completion. Penalties for failing to address incomplete documents were instituted. Those records that failed the automated compliance check were culled from the full list of records and returned to each attending for manual addenda. In the rare cases where the level of service did not meet HCFA requirements, bills were not submitted for those services. This ensured 100% compliance before records were submitted for payment and entry into the patients' charts. RESULTS: Median values of the compliance for the whole attending staff are shown in Table 1 below:Table 1These data show that compliance was fair after DG, then improved and was sustained after remuneration was instituted. CONCLUSIONS: AARK can be used to ensure timely, accurate and fully HCFA compliant records are produced and submitted. However, database analysis and feedback by itself was insufficient to fully change behavior. Additional behavioral change required incentives. In this case $5/case was sufficient to motivate the attending staff to fully document the services being provided in 90% of the cases, Continual database analysis gives the department the assurance that all necessary documentation is present. The absence of documentation can be wrongly interpreted as lack of service. Use of the AARK guarantees that all bills are submitted only where documentation exists of the service provided. The exact savings are hard to calculate, but, based upon the punitive and unreasonable settlements at other academic institutions for "fraudulent billing", savings could amount to millions of dollars.