Running Head: HIM 360 h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h h 1
7-2 Final Project Submission: Monthly Compliance Report
HIM 360
SNHU
February 25,2022
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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 have revealed that there were
certain errors due to which several charts failed to meet the documentation level for the
‘Family Practice Charges Claims’ codes. 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. h
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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. In order 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 has to 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 necessary standards and regulations, hamper patient care as
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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
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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 alow complexity medical decision-
making level. The other two charts belong to the straightforward level category. The
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organization must ensure that the providers have knowledge of factors that help to determine
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
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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. h h
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, 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
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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 in order 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
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place can result in a number of 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, andenforcement of standards.The
formal compliance program that is in place has been carefully analyzed. 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 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). In order to enhance the coding process in the organization, there is a
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need of making a number of 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 on the basis of procedures, diagnosis, symptoms, signs,
and causesof 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. 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.
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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
on the basis of simple criteria such as gender, age, and more.
D.
In order 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 in order 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 in order 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.
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.
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In order 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 amount 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.
A number of 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 in order 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 in order 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, in order 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.
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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
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 and every 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.
On the basis of the in-depth assessment, it can be concluded that the overall status of
the coding program of SNHU Medical Clinic is decent. However, since a number of errors
were located 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 current 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
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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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