There are always several documents that are waiting on physicians to sign.  Most of the time, each document (usually progress notes and history & physical notes) needs a signature from theAttending Physician and one from the Resident Physician.  It would get time consuming to go through the documents regularly to find which documents were missing signatures.  So, to make it easier, I created a spreadsheet listing the doctors who had deficiencies, the patient, date of the exam, and which of the two signatures were absent.  I added boxes to check them off as they get signed.  Now the list can be easily updated, printed and left on the physician's table to prompt the physicians to get their signing taken care of.

I was given the opportunity to sit in on a Triple Check meeting.  This meeting is a monthly process that is designed to review the facility's Medicare claims before submitting the claims to Medicare.  If there are errors in billing Medicare it can cost the facility a significant amount of money.  It is important to review the quality and accuracy of the claims being submitted.  Those who attend these meetings are Orchard Park is the MDS Coordinator, the Director of Medical Records, the Director of Therapy, and the Business Office Manager (Billing).  Each of them bring information to the table, so-to-speak, to help with the review.  The medical records department provides information from the health record, varification of names and social security numbers, and the first 7-9 diagnosis codes.  Dianne's also had the job of filling in the form documenting the review and indicating any deficiencies.  Basically, triple check is a thorough 3-way check of each UB-04.  This process usually includes a review of the following for data accuracy, coding, and placement of information on the form:

• MDS RUG (Resource Utilization Group) code and applicable billing days

• MDS submission date and acceptance

• ARD (Assessment Reference Date) and HIPPS (Health Insurance Prospective Payment System) codes for accuracy and compliance

It was so interesting for me to be able to attending this meeting and learn more about MDS and Medicare billing, and the importance of accurate data in medical records.

Reference:

Clean medicare audit results start here. (2013, Sept 11). SNF Solutions website, retrieved from http://snf-solutions.com/clean-medicare-audit-results-start-here/

When the facility has new admits, we would check the information in NetSolutions to make sure that all the needed information was there, such as the patient's social security #, Medicare #, address, contacts, guarantor, and phone numbers.

During my practicum experience I was able to gain a much better understanding of the "life" of a medical record at Orchard Park.  I learned how to assemble them, which documents were critical, how they were maintained, and what happens to the records ofter a patient is discharged.  For a review of the life of the medical record at Orchard Park, please click on the button below.