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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 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. aa
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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
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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 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.
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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
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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
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.
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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. aa
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.
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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). 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
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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 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
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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 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
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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 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
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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.
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
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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
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
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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 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
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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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