Automated documentation error detection and notification improves anesthesia billing performance.
BACKGROUND
Documentation of key times and events is required to obtain reimbursement for anesthesia services. The authors installed an information management system to improve record keeping and billing performance but found that a significant number of their records still could not be billed in a timely manner, and some records were never billed at all because they contained documentation errors.


METHODS
Computer software was developed that automatically examines electronic anesthetic records and alerts clinicians to documentation errors by alphanumeric page and e-mail. The software's efficacy was determined retrospectively by comparing billing performance before and after its implementation. Staff satisfaction with the software was assessed by survey.


RESULTS
After implementation of this software, the percentage of anesthetic records that could never be billed declined from 1.31% to 0.04%, and the median time to correct documentation errors decreased from 33 days to 3 days. The average time to release an anesthetic record to the billing service decreased from 3.0+/-0.1 days to 1.1+/-0.2 days. More than 90% of staff found the system to be helpful and easier to use than the previous manual process for error detection and notification.


CONCLUSIONS
This system allowed the authors to reduce the median time to correct documentation errors and the number of anesthetic records that were never billed by at least an order of magnitude. The authors estimate that these improvements increased their department's revenue by approximately $400,000 per year.
Spring
Stephen F
SF
Department of Anesthesia and Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston 02114, USA.
Sandberg
Warren S
WS
Anupama
Shaji
S
Walsh
John L
JL
Driscoll
William D
WD
Raines
Douglas E
DE
D000758:Anesthesia / Q000191:economics*; D004282:Documentation; D006751:Hospital Information Systems; D006801:Humans; D019451:Information Management; D007349:Insurance, Health, Reimbursement; D016347:Medical Records Systems, Computerized; D013997:Time Factors