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Development and evaluation of a charge capture program for long-term care providers
Steven M Handler1, Vincent C Hsieh, David A Nace
1The Division of Geriatric Medicine, the University of Pittsburgh Institute on Aging, the Center for Biomedical Informatics, Pittsburgh, Pennsylvania 15213, USA. steven.handler@verizon.net
Journal of the American Medical Directors Association
|September 11, 2004
Summary
A new handheld charge capture program improved coding accuracy by 20% for long-term care clinicians. The program also enhanced user satisfaction and documentation completeness compared to traditional paper methods.
Area of Science:
- Geriatric Medicine
- Health Informatics
Background:
- Clinicians face challenges in assigning appropriate Current Procedural Terminology Evaluation and Management codes.
- Accurate coding is crucial for reimbursement and quality of care in long-term care settings.
Purpose of the Study:
- To develop, implement, and evaluate a handheld charge capture program for long-term care providers.
- To assess the impact of the program on coding accuracy and clinician satisfaction.
Main Methods:
- A pre-post study design was employed.
- Coding accuracy and clinician satisfaction were assessed before and after program implementation.
- Six clinicians in long-term care settings participated.
Main Results:
- Coding accuracy improved by approximately 20% with the handheld program compared to paper-based processes.
- The majority of clinicians reported the handheld program was more available, efficient, and easier to use.
- Clinicians documented more completely and accurately using the handheld program.
Conclusions:
- A handheld billing and coding program is feasible for long-term care clinicians.
- The program significantly improves coding accuracy and clinician satisfaction.
- This technology offers a viable alternative to traditional paper-based charge capture.