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Document and Discharge — the system will do the rest. The system automatically validates the completeness of the Nurses Documentation and calculates an APC level score. It also automatically generates the appropriate level charge. The APC calculation rules and scoring system can be configured for each individual customer. The system has the ability to generate charges automatically based on a set of completed procedures.

Key Benefits

• Applies current CMS billing rules
• Captures data from EMR templates
• Eliminates the nurse’s need to complete “charge sheet”
• Decreases the number of “down-coded” charts
• Calculates Evaluation & Mgmt. (E/M) Level
• Codes all billable procedure codes
• Measures compliance to JCAHO
• Interfaces with hospital billing system
• Kept current to all CMS rule changes
• Consistently applies APC coding rules
• Consistently calculates billable charges
• Summary page helps to validate HCPCS codes
• Helps to avoid errors and incomplete documentation
• Meets and exceeds HCFA documentation requirements
• More complete documentation than handwritten
• Generates configurable internal billing codes

Key Features

• Scores/Charges automatically generated on discharge
• Data Completeness is continuously validated
• Scores/Charges Summary Reports is available

Data Captured

• Patient identification information
• Arrival mode
• Triage assessment and interventions
• Primary and secondary assessments
• Vital signs
• JCAHO required standards:
  • Pain scale
  • Safety issues
  • Nutritional assessment
  • Response to medication
  • Disposition Education
  • All injections and IV infusion therapy