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Abstract: Here, two nurse executives suggest how to identify nurse-specific outcomes indicators for the cardiac setting.

Q

At our hospital we've taken on a major compliance initiative to ensure appropriate charges and accurate, consistent billing procedures. I've been asked to work on the project team to provide input on RNs' involvement in the compliance activities and to prepare an action plan for nursing's contribution to the effort. What compliance issues do nurses need to watch for?

Denise Ringer, RN, MS, Consultant, Latham, N.Y, responds: The General Accounting Office, the financial auditing arm of Congress, estimates that Medicare and Medicaid fraud cost $27 billion last year. As a result, several initiatives were enacted to help recoup these purported losses.

Hospitals across the country were accused of committing fraud when in fact they had done nothing more than make billing errors. Under the False Claims Act, hospitals incur a minimum mandatory penalty of $5,000 for each lab test that's double-billed, billed but not done, or billed and not ordered. Damages can be astronomical, often forcing hospitals to agree to costly settlements. Hospitalwide compliance programs are essential.

Nurses, like other members of the hospital staff, must know how to avoid these serious offenses and how to report any unresolved concerns. These commonsense measures are important regardless of who pays the hospital bill. Nurses need to work with physicians to ensure that they order and document appropriate tests and procedures. Nurses should clarify with the physician any duplicate orders or orders that ap pear unnecessary. Nurses should also pay special attention to verbal orders and canceled orders in terms of followup.

Another problematic area: hospitals billing patient transfers as discharges. I'm aware of one hospital where the computer automatically defaulted to "routine discharge. Staff not paying careful attention often selected this option when a patient was actually transferred to another facility.

Compliance programs also should include education on pre- and post-practice measures and the chain of command nurses should follow to report suspected areas of abuse.

Anne Woods, RN, MSN, CCRN, CRNP, Critical Care Nurse and Adult Nurse Practitioner, Exton, Pa., answers: Today, clinical nurses at the bedside have a unique opportunity to impact billing practicesmuch more than our counterparts in previous years. As the primary caregivers, nurses serve as gatekeepers for all care and diagnostic tests done on our patients.

Nurses need to check physician orders carefully for accuracy and duplication. It's not uncommon for the attending physician, resident, intern, or medical student to duplicate orders written by another physician simply because she didn't check the chart carefully. Also, when a physician writes an order to confirm a suspected diagnosis, she should clearly state the reason for the test in the progress notes. Third-party payers won't reimburse for diagnostic tests not substantiated in the medical record. The nurse can act as a patient advocate by checking the progress notes for these inclusions.

For laboratory diagnostic blood tests, the most frequently ordered tests for any patient, nurses must know the implications of correctly obtaining specimens. Drawing the wrong tubes of blood or the incorrect amount of blood for a test incurs additional cost. When the laboratory rejects a specimen due to hemolysis or insufficient quantity, the patient and the institution absorb the added cost.

Using the correct test for the differential diagnosis impacts billing compliance as well. Several years ago, patients being ruled out for myocardial infarction routinely underwent a multitude of laboratory tests to verify the diagnosis. Physicians commonly ordered creatine phosphokinase (CPK), CPK with MB indexes, and lactate dehydrogenase with isoenzymes. Today, using a troponin 1 level is much more efficient, accurate, and cost-effective for the institution and the patient. It's the nurse's responsibility to collaborate with the physician to ensure that the patient receives the correct tests.

In the past few years, we've learned of the impact of circadian rhythms on diagnostic tests. Drawing blood at routine times of day can give the clinician an inaccurate picture of the patient status. The physician must then reorder the tests to verify the result. Not only is this procedure uncomfortable for the patient, it incurs unnecessary cost.

By paying close attention to diagnostic tests that are affected by circadian rhythms, the nurse can decrease the frequency of repeating lab studies.

The primary nurse should document all procedures in the medical record. The old saying, "If it wasn't documented, it wasn't done," has never been more true, especially in regard to patient billing practices.

# posted by Medical Information : 3:33 AM