Running Head: HIM 360 l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l l 1
7-2 Final Project Submission: Monthly Compliance Report
HIM 360
SNHU
February 25,2022
Preface
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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. l
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
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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 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
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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.
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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 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
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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. l l
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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 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).
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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 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
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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
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
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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.
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
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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.
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.
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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.
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 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 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
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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.
References
Compliance program description - main line health. (2021). Retrieved February 12, 2022, from
https://www.mainlinehealth.org/-/media/files/pdf/basic-
content/about/policies/compliance-program-description.pdf?la=en
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Documentation guidelines for CPT E&M Codes. CUIMC Office for Billing Compliance.
(2018, January 24). Retrieved February 24, 2022, from
https://www.compliance.cuimc.columbia.edu/compliance-standards/evaluation-and-
management-e-m-guidelines/documentation-guidelines-cpt-e-m-codes
Giannangelo, K. (2019). Healthcare code sets, clinical terminologies, and
classificationsystems(4th ed.). Chicago, IL: AHIMA, American Health Information
Management Association.
Jg, K., Yitambe, A., & Go, O. (1970, January 1). [PDF] improving the quality of clinical coding
through the training of Health Records and information officers in selected hospitals,
Nairobi City County, Kenya: Semantic scholar. improving the quality of clinical coding
through the training of Health Records and information officers in selected hospitals,
Nairobi City County, Kenya: Semantic scholar. Retrieved February 12, 2022, from
https://www.semanticscholar.org/paper/Improving-the-Quality-of-Clinical-Coding-
through-of-Jg-Yitambe/a0359b62da070dcfe0bfa43c109c36186374349c
National Institutes of Health. (2021). U.S. National Library of Medicine. Retrieved February
12, 2022, from https://www.nlm.nih.gov/healthit/snomedct/index.html
Oachs, P. K., & Watters, A. L. (2016). Health information management: concepts,
principles,and practice (5th ed.). Chicago, IL: AHIMA, American Health Information
ManagementAssociation.
Quinn, F. (2017, March 29). Clinical Decision Support: Using the CDS Tools in HER
Technology. Retrieved from https://medcitynews.com/2013/11/clinical-decision-
support-using-cds-tools-ehr-technology/
