Development and evaluation of a charge capture program for long-term care providers.
OBJECTIVE
Clinicians often have difficulty determining the appropriate Current Procedural Terminology Evaluation and Management code to assign to the type and intensity of patient care they provide. The purpose of this study was to develop, implement, and evaluate a handheld charge capture program for use by providers in the long-term care setting.


METHODS
Using a pre-post study design, we compared the coding accuracy and user satisfaction of an established paper process with a handheld charge capture program created for this study by means of: (1) preimplementation and postimplementation assessment of coding accuracy, and (2) preimplementation and postimplementation clinician survey.


METHODS
We studied an academic division of geriatric medicine.


METHODS
Participants consisted of six clinicians who currently spend at least 50% of their clinical time practicing in the long-term care setting.


METHODS
A handheld charge capture program to replace the current paper-based charge capture process was reviewed.


RESULTS
Overall coding accuracy improved by approximately 20% when the handheld program was used instead of a paper coding process. The majority of clinicians found that the handheld program was more widely available, efficient, easier to use, and encouraged the participants to document more completely and accurately in the patient's medical record.


CONCLUSIONS
A handheld billing and coding program used by clinicians who provide care for long-term care residents is not only feasible, but leads to an improvement in coding accuracy when compared with a paper process. In addition, clinician satisfaction toward the billing and coding processes improved with the use of the handheld program.
Handler
Steven M
SM
The Division of Geriatric Medicine, the University of Pittsburgh Institute on Aging, the Center for Biomedical Informatics, Pittsburgh, Pennsylvania 15213, USA. steven.handler@verizon.net
Hsieh
Vincent C
VC
Nace
David A
DA
Sciulli
Linda
L
Fridsma
Douglas B
DB
Studenski
Stephanie A
SA
D001291:Attitude of Health Personnel; D001292:Attitude to Computers; D003200:Computer User Training / Q000592:standards; D034201:Computers, Handheld / Q000592:standards*; D020000:Decision Support Systems, Clinical / Q000295:instrumentation; D017598:Efficiency, Organizational; D005260:Female; D005568:Forms and Records Control; D006801:Humans; D008134:Long-Term Care; D008297:Male; D016347:Medical Records Systems, Computerized / Q000592:standards*; D010818:Practice Patterns, Physicians'; D014481:United States