I was curious to know if anyone had worked on education for respiratory therapy documentation. I was asked by their manager to speak with them about reimbursement, DRGs and documentation. Thanks!
I would focus on several things relating to RT documentation: verification of continuous hours of mechanical ventilation, documentation of respiratory findings and interventions that would help support a physician diagnosis of acute respiratory failure, and documentation of RT findings/treatments used in other respiratory diagnoses. Let them know about the relationship between respiratory diagnoses, mechanical ventilation, and DRG assignment/reimbursement/case mix/GLOS. Also, you can remind them, as you would with any non-physician group, that although physician diagnoses and procedures drive DRGs, interdisciplinary inconsistency within the medical record can raise the risk of denials during audit and may suggest a failure to meet recognized clinical standards of care. Therefore they need to be sure their documentation is consistent with that of the physicians and nurses and does not reflect any meaningful discrepancies.
Hope that helps.
Renee
Linda Renee Brown, RN, CCRN, CCDS Senior Consultant, Nursing/CDI Jacobus Consulting, Inc.
Comments
I would focus on several things relating to RT documentation: verification of continuous hours of mechanical ventilation, documentation of respiratory findings and interventions that would help support a physician diagnosis of acute respiratory failure, and documentation of RT findings/treatments used in other respiratory diagnoses. Let them know about the relationship between respiratory diagnoses, mechanical ventilation, and DRG assignment/reimbursement/case mix/GLOS. Also, you can remind them, as you would with any non-physician group, that although physician diagnoses and procedures drive DRGs, interdisciplinary inconsistency within the medical record can raise the risk of denials during audit and may suggest a failure to meet recognized clinical standards of care. Therefore they need to be sure their documentation is consistent with that of the physicians and nurses and does not reflect any meaningful discrepancies.
Hope that helps.
Renee
Linda Renee Brown, RN, CCRN, CCDS
Senior Consultant, Nursing/CDI
Jacobus Consulting, Inc.