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7-2 Final Project Submission: Monthly Compliance Report
HIM 360
SNHU
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Preface
The purpose of the monthly compliance report is to capture the deficiencies that exist in the
coding process in the SNHU Medical Clinic. A detailed compliance plan has been presented in the
report with suitable recommendations in necessary areas. On an annual basis SNHU performs
auditing of provider charts for maintaining and ensuring coding compliance. A generated audit
summary report was examined to locate inefficiencies. It helped to identify areas that needed
improvement so that the goals of the SNHU Medical Clinic can be attained. The compliance plan
that has been designed can play an integral role to strengthen the current compliance framework
in the facility. It can play to strengthen the current compliance approach.
A detailed evaluation has been conducted by focusing on a diverse range of areas such as the
outcome, coding guidelines, review process, as well as EHR System. Each of these areas have
helped to understand the quality of compliance relating to coding practices in the clinical facility.
The outcome of the provider chart audits has revealed that there were certain errors due to which
several charts failed to meet the documentation level for the ‘Family Practice Charges Claims’
codes. n In the health care setting, it is necessary to understand the importance of codes and
suitable coding guidelines as it can have a direct implication on the quality of care that is delivered
to the patients. In the health care context, the thorough evaluation process that was adopted
revealed that there was a need to revise the existing review process relating to clinical
documentation. This is because a proper review of documentation can help to identify gaps. In the
health setting it can add value by ensuring that close attention is paid to details and vital
information. Additionally, the staff must be given adequate training on the application of suitable
codes. n
The importance of a well-functional compliance program has also been captured since it can play
an instrumental role in the detecting, preventing, and responding to requirements relating to
federal and state laws. To ensure that proper compliance is in place it is critical to understand the
importance of the Office of Inspector General (OIG) specifications. A broad range of
recommendations has been made relating to diverse areas such as enhancing the coding process,
improving the clinical documentation processes, focusing on the quality measures, focusing on the
training aspects of the employees in the health care facility, identification of instances of fraud or
abuse, introduction of additional technology and additional resources and having a well-defined
audit schedule in place and conducting detailed evaluation. The recommendations have been
designed at a comprehensive level so that the coding practices in SNHU Medical Clinic can be
strengthened and it can comply with suitable and relevant coding standards and guidelines. For
strengthening the coding process in an integrated manner, the staff must be trained and educated
relating to the latest coding practices. It is highly critical to ensure that they comply with the
necessary requirements and follow a systematic coding approach while carrying out their roles and
responsibilities. Similarly, the integration of new technology such as an electronic software
program can be critical to automate the current auditing activity since it can help to eliminate
errors that may arise due to the manual auditing process. In the final compliance report the
coding process of the clinic has been examined. Additionally, stress has been laid on the
documentation and compliance aspects that must be taken into consideration in the health care
setting.
Evaluation
Accurate and complete medical records is imperative for the success of healthcare organizations.
The lack of accurate and complete medical records can affect the organization’s ability to meet the
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necessary standards and regulations, hamper patient care as well as satisfaction level, and lead to
poor financial performance (Giannangelo, 2019). Comprehensive documentation ensures that
medical records aid in billing to payers for the services provided. A medical record audit must be
performed to ensure that providers are accurately following documentation procedures. The audit
can help in locating documentation-related weaknesses and help healthcare organizations to
ascertain the educational needs of the providers.
An annual audit was conducted in 2019 as a part of Southern New Hampshire University’s coding
compliance process relating to ‘Family Practice Charges Claims.’ Every provider’s previous 90 days
encounter was used to create a table. Then ten random charts per provider were chosen by using
the evaluation and management codes relating to new and existing patient office visits. It was
followed by copying or printing of the medical documentation on these charts which were sent to
the auditor for evaluation purposes. The exceptions located during the audit process were
captured in a spreadsheet. In the summary section of the spreadsheet, the charts that did not
meet the necessary documentation level were listed.
The audit process revealed that out of 150 charts that were evaluated, 9 charts failed to meet the
required documentation standard for the code that was billed. These 9 charts had used the
evaluation and management code 99214(Oachs & Watters, 2016). The encounters 502, 2426,
3255, 4884, 5157, 5556, and 6666 supported the evaluation and management code 99213. The
encounters 4612 and 6998 supported the evaluation and management code 99212. They wrongly
billed the payers $ 1,737.00 instead of $1,066.00. Thus, the payers were overbilled by $ 671.00.
The review of seven operative notes including 21A, 22A, 23A, 24B, 25C, 26C and 27C was done for
ensuring nothing was missing.5 of them had missing components. The observation of the
operative notes at the comprehensive level is descent; however, the documentation lacks
consistency. Provider 4’s documentation is extremely inconsistent as his 3 charts had 10 errors.
The healthcare organization must offer additional training to providers, physicians and medical
staff relating to accurate documentation standards, reviewing of policies and procedures, and
safety. It will help in meeting the standards set by The Joint Commission and help to pass future
audits. It will help reduce reimbursement delays, facilitate correct coding, and maximize
reimbursement. By ensuring that accurate documentation enters medical records, correct services
can be billed to payers (Oachs & Watters, 2016). A billing specialist must review the provider’s
documentation for ensuring it supports the chosen code. Annual training must be provided to the
medical billing and coding staff so that they can update their knowledge of the latest billing
policies, coding standards and other areas. In case coders are confused by any documentation
element they must get it clarified from the providers.
The E/M code reporting is done based on history, physical examination, and medical decision-
making (Giannangelo, 2019). While reviewing the summary of the audit it was observed that the
providers struggled to ascertain the medical decision-making level for each patient. It caused the
nine charts to fail to meet the documentation level for the chosen codes. Giannangelo (2019) has
stated that medical decision-making is highly cognitive of the three criteria for assessing E/M
codes and it is extremely difficult to quantify (p.73). The four levels of medical decision-making are
high complexity, moderate complexity, low complexity and straightforward. 99214 is the E/M code
that was inaccurately used in the 9 charts and the level of medical decision-making is moderate
complexity. The audit’s summary section shows that 7 out of 9 charts have allow complexity
medical decision-making level. The other two charts belong to the straightforward level category.
The organization must ensure that the providers have knowledge of factors that help to determine
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the level of medical decision-making. The chart presented below shows how the medical decision-
making level is ascertained. In documentation, two out of three factors must be included for
coding the level of medical decision-making. The charts with discrepancies must be rectified by the
provider so that medical coders can reassign accurate codes and mend overpayment problems.
Medical Decision-making levels
Complexity levels
Diagnosis or
management
options (#)
Complexity of
data reviewed
Risk of
complications,
morbidity or
mortality
Straightforward
Minimal
None or minimal
Minimal
Low
Limited
Limited
Low
Moderate
Multiple
Multiple
Moderate
High
Extensive
Extensive
High
(Giannangelo, 2019 p.74)
As part of SNHU’s coding compliance, the annual audit of provider’s chart must be continued. The
Office of the Inspector General (OIG) will advise the healthcare organization on recognizing issues
and addressing them. The OIG’s coding accuracy rate is 95 % and they expect all providers to
maintain it. The development and implementation of a clinical documentation improvement (CDI)
program is necessary. Oachs and Watters (2016) have stated that as per the American Health
Information Management Association (AHIMA), CDI’s purpose is to initiate concurrent and suitable
retrospective reviews of medical records for incomplete, conflicting, or nonspecific provider
documentation (p.267). This program will enable the organization to ensure alignment between
the medical records and appropriate regulations and guidelines. It will aid in patient record
completion, providing education, enhancing provider documentation and coding and patient care. n
The CDI program can be successful if everyone works cohesively in the healthcare organization. A
successful CDI program can facilitate progress towards value-based care instead of fee-for-service
model. An EHR system with pre-designed data elements will help providers to enhance
documentation quality and overall efficiency. The program enables providers to document when a
patient is being cared for. Thus, CDI reviewers can review the records when they are being
created. So, errors can be identified faster and providers and coders can spend extra time on
other patients which can increase the workflow. Providers must understand that CDI helps to
ensure proper documentation is in place for supporting billed codes. Documentation acts as
evidence relating to why a code is used for billing a payer. Provision of training on documentation
and CDI process can help professionals to understand their roles (Quinn, 2017). Training can be
provided in the form of real, practical documentation examples, learning of specific
documentation for specific coding systems, use of templates for documentation problem areas,
discussion on important documentation, CDI process and how they work, and creating posters,
and newsletters for increasing awareness level of respective roles and creating pocket cars for
reference purpose (Oachs & Watters, 2016 p. 275). These training tools and techniques must be
regularly monitored and they must be offered regularly or as required by the staff.
The prevalent EHR system is effective for documentation and offers suitable criteria for quality
measures reporting. The issues arise since the providers struggle to use the system for charting,
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rush the charting process or do not pay attention or lack the understanding of what has to be
charted. The EHR system must be upgraded to include charting services techniques so that
providers’ time spent on charting can be saved. A checklist must be included to ensure providers
document comprehensive information (Quinn, 2017). The system must encompass a clinical
decision support (CDS) component to locate errors and boost accuracy in documentation. Some
CDS tools are computerized alerts, templates, reminders (Quinn, 2017). The billing and coding
software of the system can minimize coding errors. In spite of using technology, the possibility of
errors exists. Training of providers and medical staff on EHR system and documentation is
imperative. The entire healthcare staff must understand the organization’s policies and procedures
and medical standards. The policies and procedures must list staff expectations, training details,
etc. The organization must ensure that audit is continuously conducted, provider documentations
are monitored, and training is provided to the staff. Adopting such holistic measures can ensure
the success of the healthcare organization.
Compliance and Recommendations
I. Compliance
A.
A compliance program refers to formalized effort to detect, prevent, and respond to conduct the
operation of a business that is inconsistent with state and federal laws (Compliance program
description - main line health, 2021). The importance of compliance programs is that it ensures
that the organizations adhere to the applicable state as well as federal laws and other
requirements of the healthcare sector. It helps in protecting practices against abuse, waste, fraud,
and other liability areas. One of the significant benefits of having a formal compliance program is
that it helps in establishing an organizational culture that promotes detection, resolution, and
prevention of conduct not conforming to the law or ethical policies of the organization. Another
prominent benefit is that it helps in reducing the risk of improper or unlawful conduct. Not having
a compliance program in place can result in several disruptions in the delivery of patient care. It
may even result in fines and other legal consequences.
B.
Office of Inspector General (OIG) plays an important role in ensuring honesty and integrity in the
healthcare institutions in the US. The vital elements of OIG classifications include written
procedures and policies, effective education and training, effective lines of communication,
designated compliance committee and compliance officer, internal auditing and monitoring,
prompt response to identified problems, and enforcement of standards. The formal compliance
program that is in place has been carefully analysed. It is found that the compliance program
meets all the requirements of the OIG specifications. It is appropriate for the specific clinic type
and meets the needs of the facility.
C.
In case the compliance plan is not adhered to, it can result in several negative consequences. It
can affect the delivery of quality care to the patients in the healthcare setting. Moreover, it may
even give rise to several legal issues. To ensure optimum compliance with the plan, the
organization needs to monitor it carefully. For effective monitoring, the goals can be broken down
into several manageable steps. Then, the steps can be monitored with the help of compliance
staff, either from outside or inside the facility, as per the requirement. A change that needs to be
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done in order to improve the usefulness of the compliance program is to ensure that there is a
dedicated person for each department. This will help in lowering the chances of any confusion at
the time of audit.
II. Recommendation
A.
The quality of clinical coding is becoming increasingly important in the healthcare setting (Jg et al.,
1970). To enhance the coding process in the organization, there is a need of making several
adjustments. The staff members of the healthcare organization must be provided with additional
education to allow them to gain a better understanding of the complete coding process. They
need to be provided with sufficient information relating to the coding guidelines. It also includes
the HCPCS Level I and II. Moreover, they must also be given education relating to documentation
guidelines specific for E/M services as well as NCCI PTP edits. It will help them in becoming more
familiar with the coding process and avoiding the chances of potential errors.
B.
Another improvement in the clinical documentation processes is the application of SNOMED CT. It
is a suite of designated standards used in the US Federal Government systems for clinical health
information exchange (National Institutes of Health, 2021). It is a comprehensive clinical
healthcare terminology that enables meaning-based retrieval. The system breaks down the
terminology based on procedures, diagnosis, symptoms, signs, and causes of injury. It also has
description tables that offer flexibility to express different clinical concepts. With an effective
coding program, it becomes easy to reduce errors and enhance the accuracy of claims. SNOMED
CT helps in enhancing the quality of clinical reporting. n It helps in effective sharing as well as the
recording of clinical data like a list of patient problems and medical histories in the EHRs. It helps
in enhancing healthcare quality measures by improving effectiveness, timeliness, and safety of
care. It also enhances the overall patient outcomes by facilitating early identification of health
issues, effective monitoring of patient health, and responding to changes in clinical practices. It
allows targeted and accurate access to healthcare information, reducing the chances of errors and
costly duplications.
C.
In reference to quality measures, these improvements can result in more accurate determination
of a patient population through the tracking of procedural trends and diagnosis based on simple
criteria such as gender, age, and more.
D.
To meet the requirements of healthcare data reporting and to attain the standards of the industry,
it is important to provide the medical staff with appropriate training. For effective training of
medical staff, a refreshed presentation can be created. It will ensure that all the staff members are
well equipped with the basic tools to meet compliance goals. All the staff members need to be
properly certified. In case they are not certified, they must be provided with the essential
resources to ensure better compliance. Chart audits can be conducted on a regular basis, and then
the final report can be submitted to the compliance committee. It will help in determining
whether the medical staff and healthcare providers require more education or not.
E.
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Fraud, as well as abuse, is frowned upon in the healthcare industry. Fraud can be defined as the
intentional misinterpretation of documentation that leads to unauthorized payment or benefit.
Some of the prominent examples of fraud are misrepresenting dates, submitting claims of specific
services that are not rendered, and misinterpretation of service descriptions or duration. Accuse
can be defined as the act performed beyond the acceptable standards of medical necessity or
professional conduct. In case the auditors suspect any kind of abuse or fraud, it is important to
document who has committed the fraud or abuse. In addition, it is also essential to note when
and where the fraud or abuse was committed. Other important details need to be noted. If the
auditors suspect any kind of abuse or fraud, they need to report the authorities, such as the
Department of Health and Human Services.
F.
To improve the functions of the current process in the clinic, it is important to implement the right
technology. For this clinic, it is important to avail of an upgrade of the technology. However, as
the number of errors is very small, it may not be required to change the workflows. In terms of
technology, a sandbox environment can be very beneficial. It is especially beneficial for testing
procedures and scenarios. This can provide the staff members with a preview of kinks that must
be worked out without causing any disruption to the current workflow. The final product is
implemented.
G.
Several additional resources may be required for the effective implementation of the
recommended technology. One of the important resources in training. Training sessions, as well as
webinars, need to be conducted before the implementation of the recommended technology. It
would be essential to ensure that all the staff members, as well as healthcare providers are able to
properly understand the technology effectively. It also provides them with an opportunity to ask
their doubts and questions relating to the technology and avail appropriate answers. It will enable
them to gain insights into what they can expect in the technology update. As the staff members
get familiar with the system, it will reduce their pressure of completing daily tasks in a timely
manner. Another resource that may be required is budget. The budget needs to be expanded. The
healthcare organizations may also consider grants to avail the required funding.
H.
The audits are to be conducted on a regular basis. It should be done at an interval of ninety days.
However, to conduct the audits effectively, it is important to have a proper schedule. It will help in
conducting the audit in a systematic manner.
I.
After evaluation, there would not be a need to modify the workflow process in the clinic. A
technology update would be sufficient to get the desired outcomes.
The compliance programs play an important role in the healthcare setting. It enhances the quality
of care and ensures adherence to state and federal laws. A strict and formal compliance plan is
essential for the proper functioning of the organization. A number of recommendations have been
given relating to the coding process, necessary improvements, quality measures, training,
technology, resources, and audits.
Conclusion
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The detailed evaluation of the coding process of the SNHU Medical Clinic has been carried out
since the proper maintaining of comprehensive and correct medical records is of paramount
importance for each health care organization. It can have a direct and significant impact on its
overall operations as well as the quality of care that is offered to patients. Based on the thorough
assessment of the coding practices, a diverse range of recommendations has been made that can
help to strengthen its compliance with the latest and relevant coding requirements such as
adopting new technology, offering training opportunities to the staff members, and conducting
regular audit activities.
Based on the in-depth assessment, it can be concluded that the overall status of the coding
program of SNHU Medical Clinic is decent. However, since several errors were in the charts it is
safe to state that the current coding program can be further improved. High emphasis must be
given to medical staff training relating to coding so that the instances of coding errors can be
eliminated, and the status can be further enhanced Currently the health care entity maintains
compliance with healthcare rules and regulations, but the coding compliance program can be
strengthened to enhance compliance. Inspite of laying emphasis on compliance, there existed
errors and loopholes in the current system in terms of coding due to which there was a lack of
complete and correct medical records. The Audit Summary captured a total of 40 errors and thus
the accuracy level was 78 %. The comprehensive evaluation that was carried out revealed that
there was scope for the health care organization to provide additional training to the medical staff
members, physicians, and others so that they could broaden their insight into documentation
standards and requirement, reviewing of policies and coding practices. The providers need to be
trained for making quality medical-related decisions while working on coding. As codes may
undergo change after a certain period, the management of the SNHU Medical Clinic must make
sure that the staff is trained on a frequent basis so that their knowledge on coding can be
expanded on an ongoing basis. The audit activity that was conducted revealed that training was a
key area that could be increased to strengthen the current coding practices and enhance the level
of compliance. SNHU must focus on regularly monitoring the program to prevent issues and
identify the training needs of its health care staff members. For improving the functions of the
current processes in the clinical facility, technology must be integrated at diverse levels. It can play
an instrumental role to enhance the efficiency and productivity of the organization. It has been
identified that an audit software can be introduced in the health care facility so that necessary
healthcare data reporting requirements can be followed. The introduction of the electronic
software program in the health care setting can basically help to automate the current processes
and help to keep a tan on the data and information that is captured by the medical staff and
physicians. The current coding practices and compliance that is adopted in the SNHU Medical
Clinic needs to be improved so that the facility can carry out its functions more effectively. The
facility must adopt a comprehensive approach by focusing on the coding guidelines, training of the
staff, integration of new technology and use of suitable resources and revising the review policies
so that the coding process can be improved. Similarly, a well-defined compliance program must be
introduced that can aid the clinical facility to adhere to the appropriate health care rules and
regulations.
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