System and Information Integrity

As hospitals add new systems that take data from the Order Entry System and pass on to the Charge Description Master (CDM) the resulting issues in documentation and charging are escalating by not having data that is correct.

Take for example if the Order is for a Left Heart Cath procedure, and the Order is sent to the GE Cath Lab system to alert the staff of a Left Heart Cath is to be performed. Once the Left Heart Cath procedure is performed then the GE System will send reports on the procedure to the physician and the hospital and send the CDM # to the CDM master file for charging. However if the data in the Order Entry is not correct and passes to the GE System the incorrect Order then the Cath Lab could perform the wrong procedure or if the GE System has the wrong CDM # then the patient will be charged incorrectly. The charging results could result as fraudulent.

MedCompliance conceived and developed the "The Information Integrity Editor". Being the first in the industry develop a system that merges Order Entry to all Subsystems to the Charge Description Master CDM into one document for system alignment and auditing of information integrity.

Our System and Information Integrity goal is:

Our System and Information Integrity project will accomplish the following objectives:

• Obtain in Excel format the following files for merging into the MedCompliance "The Information Integrity Editor":
  • Order Entry System(s)
  • Every departmental Sub System(s). Some departments such as Lab have several Sub Systems
  • CDM
  • Usage report by Inpatient and Outpatient by CDM # for past two years
• Validate with HIS that all files are accounted for
• Merge every file into the "The Information Integrity Editor". The editor will note alerts of missing data and description variances.
• Meet (on-site or off-site via Webex) with each department director to begin review of editor findings.
• First review alerts that reflect a comparison for missing elements in each file. For example: Order Entry says 2 View Chest X-ray and Radiology subsystem does not have a 2 View Chest X-ray and CDM does have a 2 View Chest X-ray then an alert is noted that Subsystem is missing the order.
• Seek from department director if missing item needs to be added to the file(s) or existing item needs to be deleted from the file(s). These will be noted on the Excel worksheet of the "The Information Integrity Editor".
• Second review alerts noted to perform description comparison that each file relates the description adequately. Not always is the description exactly the same due to personal request or system description constraints such as length of description.
• Seek from department director if any descriptions need to be changed in any file(s). These will be noted on the Excel worksheet of the "The Information Integrity Editor".
• Third review with each departmental director all items in CDM that have no usage for possible deletion from all files or if item were not being charged due to staff error or system error.
• Seek from department director if any items need to be deleted from each file. These will be noted on the Excel worksheet of the "The Information Integrity Editor".
• Send "The Information Integrity Editor" worksheet to appropriate staff member for adds, changes and deletions to their respective file(s).
• Obtain in Excel format all files again after modification are complete for accuracy by running all files again through "The Information Integrity Editor".
• Design and provide educational materials to assist in maintaining system and information integrity
• Provide educational sessions as needed

All employees of MedCompliance Services, Inc. under the direct supervision of Jessy Huebner, MAT, CHFP

Number of years offering System Information and Integrity programs and related education:

• Twenty years

Education/Training Experience:

• Mr. Huebner holds a Master's Degree in Teaching and has personally performed hundreds of OR/Surgery Case Leveling Programs. Continually staying in the trenches helping and teaching Healthcare staff members how to maintain compliance in documentation, charging and coding correctly. Fifty percent of his time is spent teaching reimbursement education with over 5,000 hours logged at the podium.

MedCompliance Services hours of operation are: Monday - Friday 8AM to 8PM EST to answer any related question the client may have.

• MedCompliance Services provides a written report at the end of each engagement.
• We track performance by auditing a sample of patient charts on a monthly basis to insure data integrity and compliance.
• We have a high customer satisfaction by responding to each and every question and/or request in a timely manner not to exceed 24 hours.

By performing the System and Information Integrity project will result in alignment of all systems as related to the CDM thus insuring Orders and Subsystem reports plus charging is correct and eliminating fraudulent charges from occurring that were caused by system issues.

It is strongly recommended establishing proper oversight and control and to maintain a high level of employee understanding of this program.

If you have questions, please contact:

MedCompliance Services, Inc.
Jessy Huebner, MAT, CHFP, CEO
800 West Avenue #1001
Miami Beach, Florida 33139