Congruence: The Challenge of Charge Capture

In the past decade we have witnessed many changes in the way healthcare services are reimbursed. Just when one regulation starts to make sense they manage to come up with new and often confusing requirements to muddy the waters just as they are beginning to clear. The one constant mantra however has remained “if it wasn’t documented, it wasn’t done”. Now those of us who have spent time delivering care in the ED know painfully well; patients don’t stagger themselves so that you may have the luxury of completing your documentation (eating your lunch, using the bathroom, grabbing the ubiquitous diet coke, wiping the stray body fluids off your scrubs…you get the idea).

The other often over-looked challenge is ED documentation is primarily for the downstream consumer. We need little documentation to communicate in the ED. Our patients (in theory) turn around relatively quickly, unlike the inpatient setting where documenting days or weeks of treatments, tests, consults and medications are required to communicate and coordinate care.

Irrespective, we just can’t seem to get away from the old “if it wasn’t documented, it wasn’t done”. This is especially true for charge capture. Let’s look at the story of Larry an ED patient that presents with chest pain. Larry loves your ED and visits often, he has a history of MI and pops in to the ED every now and then with chest pain. This is a scary patient because we know that we must take any complaints of chest pain seriously but most of the time he is completely pain-free and ready to go home after a little nitro and of course 2mg-10mg of morphine titrated to pain. When Larry presents to triage the triage nurse calls back for a monitored bed, he is placed on a cardiac monitor, given O2, IV access is established, and a 12 lead ECG is completed as well as a stat portable chest x-ray (we all know how this story goes). The ED physician comes in see what’s going on, writes the order for MS and probably a nitro drip. 2 or 3 hours later Larry’s pain is gone and he is instructed of course to follow-up with his doctor and return to the ED immediately if his pain is returns. By now you are saying; what’s your point Suzy?

The point is unless everything done for Larry was ordered and documented in Larry’s record your ED cannot charge for it. So the ED doctor saw the patient was on the monitor therefore didn’t write the order. The primary nurse didn’t clearly document the start and stop time of the nitro drip and the morphine IV push was not clearly documented, by the way documenting on your charge sheet DOES NOT count. So Larry’s visit just cost your ED approximately $151. Doesn’t seem like much, huh? But let’s say you see 35,000 visits annually in your ED and 25% of them receive the same treatment protocol as Larry, the documentation is inadequate ONLY 10% of the time, if you look at the numbers at the end of the year your ED will have lost approximately $132,000 or let’s say you miss it 30% of the time, the number goes to $396,000!

So evaluate congruence! Look at your orders and documentation, find the opportunities for improvement (I guarantee you have them!), communicate with the ED staff where you are (current state) and define a plan and strategy for where you want to be (future state). Finally, the numbers above are very conservative; many ED Directors know that the dollar figure for lost ED charges is frequently in the millions! Remember now more than ever; if it wasn’t documented, it wasn’t done!