Wiki Inpatient Fee Abstraction

[jodymarie]

I am looking for a large multi-specialty physician group that does inpatient concurrent physician coding. Our physician group would like to have coders review charts on the floor in order to have better patient capture and timely billing. We currently do retrospective coding. If your group does this type of coding would it be possible to contact you to discuss your workflow. I am looking for ideas.

 

[FTessaBartels]

Inpatient abstraction

Jody,
First, I'm talking only about abstracting PROFESSIONAL charges.

Our team of inpatient abstractors is divided into two areas.

One part of the team reviews every page of every chart of every discharged patient. This is typically done within 48 hours of discharge (usually 24 hours, except on weekends or holidays).

Another is in charge of any long-term inpatients. Patients who have been inpatient for 1 week go on that abstractor's "list." The abstractor covers the entire hospital going through the charts of all the long-term patients on her list. She marks the "last" page coded (usually a special color highlighter "dot" in the lower left corner of the page) so she knows where she left off when she comes back to that chart - OR - the post-discharge abstractors know where she left off.

Some physicians also keep a log of their visits, so that staff can reconcile against claims filed about a month after the visit date. If any were missed we can contact the abstractors with the relevant documentation and get the charge picked up. (NOTE: Not every physician is diligent about keeping the log. Some do it in a Palm Pilot or similar device; some use an actual paper notebook! One MD I know just collects the patient labels from the HUC's desk and makes a note of date and type of service and hands his poor assistant this pile of labels!)

Hope that helps.

F Tessa Bartels, CPC, CEMC