Billing and financial functions are becoming more of a clinical, rather than a billing, responsibility. These functions include obvious tasks, such as documenting proper medical justifications for billing purposes. They also include the not-so-obvious task of managing the costs of providing that care. Today, clinics are financially at risk not only for the medical care they provide but also are increasingly at risk for therapeutic outcomes, the cost of care and the integration of complex regulations in the process of care.

As a result, managing the revenue cycle is becoming more of a clinical task and medical documentation is its driver. Today, nurses and physicians often wear the chief financial officer or controller hat and bear responsibilities they typically are not trained to manage. Their challenge is surmountable with a combination of policy and procedures, staff education and digital tools designed to transparently integrate regulations into the process of care.

Nurses joined their profession to care for patients and expected to spend the bulk of their time with them. Their sole professional responsibility was clinical care. With time, as they were promoted, nurses — nurse managers in particular — were and continue to be saddled with nonclinical responsibilities that require them to balance the cost of the care with its quality and value, both defined by cumbersome, rigid regulatory metrics and fenced in by their organization’s tight budgets. As a result, the nurse manager role has shifted from clinical care to operations and finance with a laser focus on value-based care (VBC).

Although VBC may be focused on the patient, it is the clinician who bears the burden of adhering to complex reporting regulations. A clinician is schooled in medical records documentation but not in specific coding associated with labs, meds and services — coding required by CMS and other intermediaries. Billing specialists, once the locus of appropriate billing documentation, today lack the necessary credentials to document the medical justification required to ensure that treatment is compensable by CMS; because of this, clinicians now wear nonmedical caps as often as medical ones. Although physicians direct care, nurse managers typically are the ones who document the reasoning — that is, the justification — behind that care: the ICD-10 and CPT-4 codes that go on the claims.

With this new nursing role comes a risk that an inadvertent medical documentation oversight may result in a significant impact on clinics’ present and future reimbursement. In fact, according to a CERT review issued by National Government Services, “insufficient documentation causes most improper payments.” Therefore, nurses and physicians must undertake more time-consuming, unproductive work — work that once took place in the billing department — to manage care that now is intertwined with complex billing regulations. Today, a dialysis organization’s revenue is predominantly driven by clinical documentation and its transparent management during the process of providing care.

Following the bundle

For example, consider bundled billing. Based on the patient’s diagnosis or condition, its purpose is to standardize care, increase its quality and lower its cost. Ultimately, the bundle has become a cost center, not a revenue generator. Today, nurses and physicians must balance the cost of a therapy with its efficacy based on regulatory requirements. Accordingly, when regulations proliferate, prices generally increase, as in the case of erythropoietic stimulating agents (up 20% in recent years). As would be expected, nurses and physicians must pay more attention to billing details to ensure the care they provide is appropriately reimbursed.

In addition to addressing bundled billing, they must pay attention to the documentation required for conditions for coverage, CROWNWeb and quality incentive payments (QIPs), all of which push nurses and nurse managers farther from patient care and deeper into their administrative offices. QIP management has become increasingly more complex, and more facilities — independent dialysis providers in particular — are getting hit with QIP penalties from Medicare. The costs are not just financial. They may unfortunately be reputational even when the penalty is based on an administrative oversight.

Burdened with these additional duties, nurse managers are spending less time on the floor and more time in the office, sight unseen. Often, other nurses on staff view nurse managers as less of a team member as they are less available to pitch in with patient care. As a skilled knowledge worker, once accessible to them and patients, their unavailability negatively affects the morale of staff nurses who are unaware of what is happening behind closed office doors, damaging relationships.

The answer? Equip nurse managers and other clinicians with the right processes, tools and training to help them manage clinical practice from a business perspective — an evolving paradigm for dialysis practices.

Role of compliance

When clinicians document treatments, they verify the charges are accurate and complete and the facility has the requisite supporting documentation. The burden of proof belongs to the clinician, who must attest that documentation is both appropriate and timely. In addition, as I explained in the first article in this series on electronic medical records (EMRs), if there is no timely documentation of an action, then it did not occur — and EMRs track the timing of everything. The initial work should take place at patient intake, not at the end of the month when the billing process takes place. That is too late.

Problematically, if a clinician documents an order or the physician signs an order too far after the fact, the system’s audit trail will capture his late signing. CMS auditors will notice the date and time stamps during a pre- or post-claim audit. A pattern of recordkeeping deficiencies will intensify CMS scrutiny.

Not only do poor recordkeeping practices risk exposure with the CMS, but these also raise the specter of individual fraud claims against practice administrators and clinicians. In September 2015, Deputy Attorney General Sally Quillian Yates issued a memo on behalf of the U.S. Department of Justice explaining that criminal investigations will begin piercing the corporate veil and holding wrongdoing individuals accountable for their misconduct. This means that doctors, nurse managers and others can be held responsible if they knowingly falsify clinical records after the fact to create properly documented records. Couple this with the fact that CMS has hired more auditors to review records for fraudulent claims, and dialysis practices that fail to keep accurate, timely records are facing a significantly heightened risk.

Mitigating risk

An EMR system that monitors compliance during the process of care, and, to the extent possible, ensures its accurate and timely documentation, benefits everyone who documents a billable clinical charge. This kind of system must consist of four components, or layers of protection, to mitigate the risk of noncompliance with the regulations: processes, tools, education and auditing.

As the first layer of protection, dialysis practices must establish clear policies and procedures to ensure compliance with CMS regulations. The path to payment begins with a properly documented and signed order in the EMR. Auditors work backward from payment, to claim, to treatment documentation, to the order, ensuring the chain is complete. Integrating billing intelligence with the orders and treatment documentation ensures clean claims and timely payments. All treatment orders must be signed within the mandated number of hours. Treatment records should be verified for completeness at the end of the shift when the information is fresh and memorable. If any step is broken, claim payments can be delayed or denied altogether. If this occurs, you must spend time recreating the information and defending it in the appeals process to be reimbursed, all of which increases the cost of securing reimbursement. The integration of billing intelligence with clinical documentation needs to be proactive — when the order happens — rather than at the end of the month to satisfy CMS requirements.

The second layer of protection is reliance on software-mediated workflows. Your EMR should be set up so it takes the burden off you to remember the appropriate billing requirement. In short, it should deploy automatic checks and balances so that you do not have to remember the billing steps. The EMR should manage this transparently by incorporating the billing rules within the process of clinical documentation. Then, you will have confidence to prove things were done because you have the data to demonstrate it. Your EMR should mandate you have satisfied all billing requirements and justifications in real-time before closing the flowsheet.

Absent that, create manual and report-driven processes and audits that you run every day to double-check compliance. If you wait to run these reports until the end of the month, you are already too late.

The third layer of protection is taking a disciplined approach to nurse manager training. Though equipped with expert clinical skills, they now need to learn essential business skills in addition to their EMR, such as using basic business software like the Microsoft Office suite; learning basic financial terminology; interpreting budgets; and cultivating soft skills, including communication and conflict management.

The fourth and final layer of protection is periodic auditing for compliance. Digital dashboards within an EMR provide a one-stop audit of all business and financial components related to a nurse manager’s role. Dashboards should efficiently drill down to exceptions, preferably with a single click. Facilities without dashboards should run a series of manual reports to identify outliers that require remediation.


Nurses are assuming more financial and operations responsibilities than ever before, not only because of VBC but also because it intertwines with the alphabet soup of government and CMS regulations that mandate so many precise details for one billable service. A new paradigm for nurses, and specifically for nurse managers, is in the making — one recognizing that revenue is driven by clinical documentation and the revenue cycle can be effectively managed with the appropriate policies and procedures, tools, education and audits.

Today, nursing responsibilities include knowing and executing unique, interrelated regulations to prove the quality of care. They encompass providing the data to qualify the reimbursement for each service claimed and justifying the cost of care provided and, not to forget a vital component of a nurse’s personal mission, they embrace protecting their patients and ultimately their staff and the financial viability of their organization.

A new paradigm of nurse manager is surely rising in the digital age of medical care where the practice of medicine is transitioning to the practice of information on behalf of patients and dialysis practices.

Guarnieri DK. Neph News Iss. 2017;31:27-31.

For more information: David Kyle Guarnieri is with lnfian, an electronic medical record, billing software and revenue cycle management company based in Richmond, Virginia. Disclosure: Guarnieri reports no relevant financial disclosures.