Posts Tagged ‘documentation’

Indiana University School of Medicine researchers say hospital discharge summaries are “grossly inadequate” at documenting tests with pending results.

They justify this statement based on their recent study, “Adequacy of Hospital Discharge Summaries in Documenting Tests with Pending Results and Outpatient Follow-up Providers,” published in the September Journal of General Internal Medicine.

Of the 668 patient discharge summaries reviewed in the study, up to 41 percent of those patients were discharged with test results pending, and about 9 percent of those tests required changes to patient care. However, researchers found only 482 of 2,927 (16 percent) tests pending results were even mentioned. Only 13 percent of the discharge summaries actually documented all tests with pending results. About 75 percent of the discharge summaries did not mention any tests pending results at all.

This creates a real continuity-of-care challenge for primary care physicians.

“Physicians are doing a terrible job during the transition of care of informing the follow-up [practitioners] about what they should know about a patient’s pending tests,” said the study’s lead author, Martin C. Were, M.D., assistant professor of medicine at Indiana University School of Medicine and a research scientist at the IU-affiliated Regenstrief Institute, Inc.

The Indiana University researchers blame poor communication during care transition between inpatient and outpatient settings.

“Errors in communication reportedly contribute to over half of all preventable adverse events and are associated with twice as many deaths when compared with errors due to clinical inadequacy,” researchers state in the study.

Providers submitting claims to Cigna: Make sure to read the private payer’s latest Professional Claims Code Editing and Documentation Requirements Guidelines. Effective April 27, the company now requires supporting documentation for some claims containing modifiers 25 and 59.

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Although the Medicare fee-for-service (FFS) error rate has dropped from 14 percent in 1996 to 3.6 percent in 2008, that’s still billions of dollars—$10.4 billion to be exact—in improper payments.

The news is always the same. “For Medicare FFS, most improper payments are due to claims for services that were medically unnecessary or incorrectly coded,” reports a Centers for Medicare & Medicaid Services Nov. 17 press release. Read more »