ACCM Documentation for Billing Compliance

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ACCM Documentation for Billing Compliance
4/01/2006
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Complete ADR Documentation

• A legal document provides protection in the
  event of an adverse outcome (malpractice suit).
• JCAHO documentation
• Billing documentation

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Billing Documentation Audit

• Every attending will have ten charts audited each
  year.
• Any failure scores (gt12) results in repeat audit
  next quarter.
• Total failure score (gt60) results in repeat
  audit.
• Failure of two quarters results in Prebilling
  Review OBQA reviews all charges.
• Results in expensive charge to provider (from
  yearly bonus).

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Check one or both of these boxes 1 point
Preop documentation of interview and Anesthetic
Plan by attending 2 point
Attending Signature Date and Time 2 point
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Medical Direction Requirements

• Seven Requirements for Medical Direction
• Perform Pre-anesthetic evaluation
• Prescribe anesthetic plan
• Participate in most demanding aspects of the
  anesthetic
• Ensure that all procedures are performed by
  qualified, competent individuals.
• Monitor the course of the anesthetic frequently
• Remain physically present and available for any
  emergency.
• Provide indicated post-anesthesia care.

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Medical Direction Requirements

• Perform Pre-anesthetic evaluation
• Prescribe anesthetic plan

• Attending must interview all patients scheduled
  for an anesthetic
• Document this assessment including a description
  of the anesthetic plan on back of Preop ADR

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Medical Direction Requirements

• Participate in most demanding aspects of the
  anesthetic
• Ensure that all procedures are performed by
  qualified, competent individuals.

• Attending must be present for induction,
  emergence, and/or lines blocks.
• Initial appropriate blocks on ADR
• Personally perform procedures if necessary.

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Medical Direction Requirements

• Monitor the course of the anesthetic frequently.
• Remain physically present and available for any
  emergency.

• Attending must provide initials to signify
  Induction, Emergence, and periodically during
  case.
• Attendings must arrange for cross-coverage if
  they are not immediately available.

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Attending signature. Times must match. 3 points
ANES TECHIQ must indicate General and/or
Regional. 1 point
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Attending initials signifies presence for lines.
1 point
Attending initials signifies physical
presence. 3 points
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Assessment pre-induction must be signed. 1 point
PREPROC CHK must be checked. 1 point
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Medical Direction Requirements

• Provide indicated post-anesthesia care.

• Provide care and disposition of patient in
  PACU/ICU
• Document on back of ADR this disposition. ADR
  should include postop vitals recorded.

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• Attending Notes to document
• Placement of lines,
• blocks, etc.
• Significant intraoperative
• events including signout
• Postop management
• Postop Note
• Example
• OK to go to floor. No
• apparent complications.
• 2 points

Transfer of care Signature. 1 point
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Audit Points
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Typical Audit Results