Documentation of EKG in ED for reimbursement purposes

[Jennifer Boston]

Hey folks,

Quick question - we've been told that the RN or the ED tech MUST document the EkG was done for reimbursement. Documenting it has been done makes total sense...however that the RN or ED tech must be the ones to do it, does not. The ER physician's interpretation is always in the chart...wouldn't this indicate the EKG was done? We are being told that even though the ER physician has documented the EKG, if the nurse or tech hasn't documented it was done, then per CMS we can not collect.

I have searched for this reg everywhere....can anyone help me find this, or find something to support that it doesn't have to be the nurse or ED tech?

Thanks much!

[Racer15, BSN, RN]

In my ER, the EKG has to be done within ten minutes of triage (this is for CPC accredidation). It's not based on when the MD signs off on it, but when it is actually performed. That's why the RN/Tech charting is so important at my facility.

[Esme12, ASN, BSN, RN]

Altra,

Thank you for your reply. Just to clarify...if the electronic chart reflects the EKG was in fact ordered, and the ER physician has documented his interpretation of the EKG under the heading "EKG interpretation" would that not in fact satify the reg? I'm not understanding why it has to be documented by the nurse or ED tech as actually done, when it's been documented as reviewed by the ER doc and therefore had to have been done. There are many many days I think I should do chart reviews for coding as part time job...just because I can see the obvious....

NO...it does not qualify it....for charges there has to be x amount of time spent with the patient with x amount of tasks being performed. I never under stand why management doesn't share the CMS qualifying features for each level of charges so that staff can...and will document accordingly....they always act like it's a big secret...when it isn't.

For each acuity there are qualifying features that must be documented and fulfilled like how man y nurses how much time frequency of vital signs what equipment used...this is different in the ED as not all our patients are a level 5. The ICU has the monitors included in their daily charge....the ED does not for we charge only time spent and equipment used and staff utilized because it varies situation to situation patient to patient.

The government/insurances companies are not supposed to logically think....if it isn't documented as being done it isn't done.

Their job to to deny as much as possible to lower the bill so if A and C are there...... but you didn't indicate B was completed..... therefore it wasn't done. It isn't supposed to make sense. Technically, in the ED, nursing is billable...the more nursing care the higher acuity the more they can charge...but without documentation it wasn't done or didn't occur.

Document EVERYTHING including IV attempts.

[Esme12, ASN, BSN, RN]

And stupid stuff like this is why nurses want to leave the profession. It's a small thing but this silly stuff adds up over the course of a shift. The doctor can not review an EKG that was not done.... but I understand...... I'm assuming its a safety issue. Did the doctor review the correct EKG bc according to the chart an EKG was ordered but never done.......

It's not so stupid if you want to have a job and get paid. When you order food and drinks at a restaurant and the bill comes and says it's $300.00 for you and your friend...don't you want to see an itemized bill? Or do you want the waiter/ress tell you .."Well it's clear you've been drinking why do you want to know how much and what kind?"

It a billable issue....the documentation of nursing care that correlates with the acuity of the patient. The ED is one of the few areas that charges for acuity.....or charges for nursing care. Which you need in the ED.........Lets say you had one patient all night, but that patient was a multiple trauma that required to have lines inserted, chest tubes and their chest cracked and flown out...you want to account for more the ED visits 11-7: 1

Why do nurses feel that because management asks them to do something it's a pain and for JACHO and not worth their time. YOU are documenting what YOU are worth in the ED and the more time you spend the higher the acuity that more that is charged and eventually it really will trickle to your paycheck.

[Altra, BSN, RN]

I can't "like" Esme's posts above enough -- the ED is one of the few places where documented nursing care translates into actual dollars. Use that power!!

[psu_213, BSN, RN]

I can't "like" Esme's posts above enough -- the ED is one of the few places where documented nursing care translates into actual dollars. Use that power!!

I agree....although I must say that charting "bolus 1000 mL NSS complete" so you get paid for the infusion is a bit silly (as if charting that you gave it isn't proof enough, oh well).

[gcupid]

It's not so stupid if you want to have a job and get paid. When you order food and drinks at a restaurant and the bill comes and says it's $300.00 for you and your friend...don't you want to see an itemized bill? Or do you want the waiter/ress tell you .."Well it's clear you've been drinking why do you want to know how much and what kind?"

It a billable issue....the documentation of nursing care that correlates with the acuity of the patient. The ED is one of the few areas that charges for acuity.....or charges for nursing care. Which you need in the ED.........Lets say you had one patient all night, but that patient was a multiple trauma that required to have lines inserted, chest tubes and their chest cracked and flown out...you want to account for more the ED visits 11-7: 1

Why do nurses feel that because management asks them to do something it's a pain and for JACHO and not worth their time. YOU are documenting what YOU are worth in the ED and the more time you spend the higher the acuity that more that is charged and eventually it really will trickle to your paycheck.

How many EKG's? However many the doctor ordered. What kind of EKG? Whatever kind the doctor ordered.

"Eventually it really will trickle to your paycheck." Really??? I have yet to see tips, bonuses or increases in wage for charting more than the avg bear. I will believe it when I also see the many delayed promises of increased staffing or better working conditions come into fruition. It's just certain things you can't feed me. Try other members, thanks....

I'm pretty thorough with charting, if asked to chart things I DO IT...

[Esme12, ASN, BSN, RN]

How many EKG's? However many the doctor ordered. What kind of EKG? Whatever kind the doctor ordered.

"Eventually it really will trickle to your paycheck." Really??? I have yet to see tips, bonuses or increases in wage for charting more than the avg bear. I will believe it when I also see the many delayed promises of increased staffing or better working conditions come into fruition. It's just certain things you can't feed me. Try other members, thanks....

I'm pretty thorough with charting, if asked to chart things I DO IT...

I am curious do you work in a ED? There are things unique to this area of nursing....documentation is one of them as ED nurses encounter many legal cases...rape, assault, alcohol, fatalities, overdoses, suicides, trauma.......that are unique to this area and require specific documentation.

Take reimbursement away....documenting 12-lead EKG done as a part of documenting to CYA in a court of law. Litigation is common for the ED as it is a high liability area where if it isn't documented it wasn't done...period. Documentation is one of the HUGE mistakes made by nurses and physicians and is one of the highest reasons that delay of treatment lawsuits are awarded. Timeliness of treatment is as important as the treatment rendered.....in the Emergency Department. It isn't charting "more than the average bear"....it's documenting appropriately to receive appropriate reimbursement.....and to cover thy behind.

I have worked at the bedside in some of the busiest Emergency Departments..... in the nation. I understand perfectly about delayed promises, under staffing, and horrible working conditions. You can "try another member" to "feed" reasons to on why any nurse can't see how their documentation affects nursing directly in the Emergency Department....and how they "aint got no time for that".

I am always confused by the resistance from nurses when they have an opportunity to actually have their services reimbursed for and take actual credit for all those tasks completed. To actually document how impossible our jobs are.... and actually have it show up on paper for the CEO/CFO to see that yes...nurses can bring revenue.

Well......if you feel that this is unnecessary then it is clear why it hasn't been reflected to your department. I have been a ED nurse for a LOOOOONG TIME (34 years to be exact) as a bedside nurse, a manager and a director. Believe me it does make a difference. I am simply answering the OP question as to why that particular documentation is necessary. Is it ridiculous sometimes? Yes....Is it necessary? Yes.

Whether or not you choose to believe that is entirely up to you.

[gcupid]

I am curious do you work in a ED? There are things unique to this area of nursing....documentation is one of them as ED nurses encounter many legal cases...rape, assault, alcohol, fatalities, overdoses, suicides, trauma.......that are unique to this area and require specific documentation.

Take reimbursement away....documenting 12-lead EKG done as a part of documenting to CYA in a court of law. Litigation is common for the ED as it is a high liability area where if it isn't documented it wasn't done...period. Documentation is one of the HUGE mistakes made by nurses and physicians and is one of the highest reasons that delay of treatment lawsuits are awarded. Timeliness of treatment is as important as the treatment rendered.....in the Emergency Department. It isn't charting "more than the average bear"....it's documenting appropriately to receive appropriate reimbursement.....and to cover thy behind.

I have worked at the bedside in some of the busiest Emergency Departments..... in the nation. I understand perfectly about delayed promises, under staffing, and horrible working conditions. You can "try another member" to "feed" reasons to on why any nurse can't see how their documentation affects nursing directly in the Emergency Department....and how they "aint got no time for that".

I am always confused by the resistance from nurses when they have an opportunity to actually have their services reimbursed for and take actual credit for all those tasks completed. To actually document how impossible our jobs are.... and actually have it show up on paper for the CEO/CFO to see that yes...nurses can bring revenue.

Well......if you feel that this is unnecessary then it is clear why it hasn't been reflected to your department. I have been a ED nurse for a LOOOOONG TIME (34 years to be exact) as a bedside nurse, a manager and a director. Believe me it does make a difference. I am simply answering the OP question as to why that particular documentation is necessary. Is it ridiculous sometimes? Yes....Is it necessary? Yes.

Whether or not you choose to believe that is entirely up to you.

I Never stated that the documentation was unnecessary but maybe I implied it. See if there could be another implication from my responses that you failed to see. (Y not have an easier process for the nurse? Not just in regards to this but other things as well so that one extra small task that takes a few seconds won't be the straw that breaks the camel's back... Or if we must chart a narrative on everything done in order to receive appropriate reimbursement, take another demand away)

In all 34 of those years... Post evidence of a difference, the TRICKLING DOWN EFFECT to the bedside nurse... My resume doesn't reflect 34 years but it reflects enough for you to consider hiring me at any one of the nation's largest ERs. You shouldn't be able to even feed this to a two year nurse with an independent mind. How many worksheets or other tasks that are added to a nurse's workload are backed up with an increase of pay or a decrease in responsibility to another area that balances things out??

[Medic2RN, BSN, RN, EMT-P]

My ER director does an excellent job of explaining the reasons for this documentation and illustrating why we need to chart what we do. For example, stop times on IV infusions. No one was doing it. She would send us a copy of our charting with highlighted portions of what we left out and exactly how much money we, as a department, lost for a simple omission of noting the time. It was eye opening. She also lets us know what happens to the money we get reimbursed for in the ED and how it applies to the ED budget.

I must say that it has made the ER nurses realize the 'business' side of the ER. The budget money has been used for new hires and equipment we requested. I think if more nurses were included in the knowledge of the struggles of management budget issues, they would take more ownership of it instead of being in the dark and thinking that it is just more meaningless work to do.

Knowledge is power and management needs to share this with the nurses.

My ER director was hired directly from bedside, so she still relates to how we think.

[Sassy5d]

^^^^ this is exactly what I love at my place. They keep us in check with the business aspect of it too.

I think documentation in general needs to be overhauled. Many times, ill get a pt who was recently seen, the entire time in the ED only notes are triage, labs were sent and d/c. I doubt that's all that happened

[psu_213, BSN, RN]

We were told the total amount of reimbursement our ED lost by not charting completion times on infusions. It had gotten bad enough that it has now been made a bit more user friendly. For each infusion (whether it be a bolus, ABX, etc.) an icon now pops up each time an infusion is started. When complete, the nurse clicks on the icon and charts the end time for that infusion. Nurses still occasionally forget to chart infusion endtimes off even with the prompts, but we are doing better that we used to.