Wiki Lack of Documentation in HAR.

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nyckimmie

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Hello, I have an issue in where Leadership advises coders to look into other charts for documentation and I disagree. For example, a HAR (hospital account record) is created to carve out a service (ambulatory surgery, dos 11/16/22) from an inpatient stay HAR (LOS 11/15-17/22). Each has their own har # but there are no documents in the HAR carve out account, the documents are in the inpatient account. Our supervisor advises the coder to look at the inpatient account for the Op report and assign the cpt to the carve out acct. and refuses to request the op be scanned to Carve out acct., "it's ok, that's the way we do it". From a compliance standpoint I advise the coders to request that the op be scanned into the correct acct. for so many reasons. 1. Each HAR has to stand on it's own (that's the purpose of a HAR). 2. If there's a request for records there will be none in the carve out acct. to support the cpt. 3. Even a piece of paper scanned into the chart with a link "ref. inpt. har # 123 for op report" could suffice. Please let me know if any clarification is needed. If anyone would weigh in on this with opinions or guidelines, I would really appreciate it. Thank you very much.
 
I'm not sure I understand your reasoning here. Each encounter needs to stand on its own but not each HAR - if the provider's medical records system splits it into multiple accounts, I don't see why that would be a compliance issue. As long as your records department understands where the records are located and knows where to find them in the event of a medical records request, then I don't think it would be an issue. If you are requiring the same record to be copied and scanned into different accounts, you are just creating duplicate records in your system and creating extra work. Payers are only concerned that the documentation supports what was billed. They really don't care how the provider is filing in their own system or whether it's under one HAR number or multiple numbers.
 
I agree with Thomas. If the records are all housed under the same EHR, there is no reason to separately add them to each individual HAR. Unless we are not understanding your meaning fully?
 
Thank you both for your reply. A HAR is per encounter. The medical record number (EHR) is per patient, a filing system of all the HARs for that individual. The system is Epic. I really do appreciate your take on this.
 
nyckimmie said:
Thank you both for your reply. A HAR is per encounter. The medical record number (EHR) is per patient, a filing system of all the HARs for that individual. The system is Epic. I really do appreciate your take on this.
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Epic is a very complex system and there may in fact be necessary and valid reasons for creating multiple HARs for a given encounter. But I'll just stress again that as long as there is documentation to support what is billed, that is what is most critical, not how or where it is stored in the Epic system.

This is something you're going to have to work out with your leadership because without being able to review claims, records and workflows to get an understanding what is happening behind the scenes, there really isn't a definitive way to say that this is or is not compliant. If your supervisors aren't willing to give you a reasonable explanation that allays your concerns, I'd recommend asking your compliance department to investigate it and give you a more concrete answer.
 
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