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HIM 360 Module Four Audit Summary Report Template
Detailed Analysis: SNHU Medical Clinic
Date of Review: February 25, 2022
Number of Reports Reviewed: 20
Provider Audit Score: 70 %
I selected two physicians and ten charts of each provider for insurance audit purpose. The
elements that are reviewed are CPT Codes, Diagnosis codes, errors and error causes. Out of all
the charts only 6 contained CPT errors.
While reviewing the CPT codes, and diagnosis codes it was observed that physicians upcode for
medical decision-making. It could be because of not coding to maximum specificity leading to
wrong diagnosis codes and missing manifestations documentation. It is common with
Hypertension and Diabetes. This practice leads to revenue loss. It can lead to underpayment or
overpayment and the organization’s revenue may diminish or it may have to return the money
with a fine. These errors show that diagnosis is not specific. There is need for more specifications
so that coders can code for maximum specificity.
Another observation is that providers use incorrect CPT codes for existing vs. new patients. Out
of 20 charts there was a single such error. But its frequency could rise when more charts are
examined. A patient cannot be considered a new patient if he or she is seen in the organization for
any service previously. In case of such patients, the codes 99211-99215 must be used. The
registration department must ensure accuracy of these aspects and the workflow from the start.
Coders must double check since E/M coders occasionally use the codes. In the specific context it
is done by providers. However, other units in the organization must be alerted about it.
Provider 1 had most errors which decreased the accuracy rate. He can fix his error by being more
specific and capturing more information in his documentation. It can help coders to select the
best code that fits the documentation. Physician 1 also had incorrect patient status CPT code. The
registration should have correct information so that the provider can ascertain whether a patient is
new or existing.
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Provide 2 had fewer errors as compared to Provider 1. His errors were relayed to upcoding which
is due to poor documentation of manifestations and not being specific. Such errors may cause
incorrect coding, conflict documentation and the use of incorrect CPT codes. The CDI must
inquire providers about specificity to correct coding and improve documentation.
My initial step would be to identifying and reviewing the actual guidelines. Then a meeting with
the providers must be scheduled for addressing the issue. In the meeting I will explain the
documentation process and its benefits. Then training must be provided to providers about the
documentation process and the processes that they use. It can help to mend the incorrect
processes. After one month evaluation will be done to see any improvement. If problems exist
then they would be documented and methods would be found to fix them. Feedback will be taken
relating to previous training as well as the process so that I along with my staff can improve the
training and introduce the processes to the providers.
The providers must be asked whether they need additional information or not regarding the
Electronic Health Record (EHR) system and the accomplishment of the identified goals. They
will be encouraged to flag incomplete documentations by using hard stops. It will ensure that in
the succeeding sections there will be hard stops in case nothing has been input in the previous
sections. It will be helpful for all the providers as they can understand what information must be
used for accurate and complete documentation. The solution that I am recommending involves
the creation of a template, generating questions or reminder bubbles, and forming hard stops
prior to the input of next series of information. It can facilitate specified and comprehensive
documentation.
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Physician: #1 Date of Review: February 25,2022
Reviewer: Lauretta Krakue
Number of Reports Reviewed: 10
Patient
Diagnosis
Present on
Admission
CPT Billed
CPT Documented
Status: Correct or
Error
Encounter # /
Column A
Code/Column
Diagnosis Code,
or N/A
Code / Column C
Correct Code /
Column C or J,
Depending on
Whether There Is
an Error
Identified Errors in
Documentation /
Column J
1
M54.9
99214
2
R15.9
99213
3
R03.0
99214
99213
Medical decision-
making used for
claim upcoding
4
R73.09
99213
5
E11.65
99202
99212
New patient codes
cannot be used if he
or she is seen by a
provider in the
same hospital
group
6
Z01.810
99213
7
I49.9
99213
8
E11.9
99214
99213
Medical decision-
making used for
claim upcoding and
accurate diabetes
mellitus code not
used
9
E11.65
99214
10
D64.9
99214
99213
Medical decision-
making used for
claim upcoding
Physician: #2 Date of Review: February 25,2022
Reviewer: Lauretta Krakue
Number of Reports Reviewed: 10
Patient
Diagnosis
Present on
Admission
CPT Billed
CPT Documented
Status: Correct or
Error
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Encounter # /
Column A
Code/Column
Diagnosis Code,
or N/A
Code / Column C
Correct Code /
Column C or J,
Depending on
Whether There Is
an Error
Identified Errors in
Documentation /
Column J
11
I10
99213
12
I10
99214
13
J01.00
99214
99213
Medical decision-
making used for
claim upcoding
14
E11.40
99213
15
R74.9
99213
16
J32.9
99213
17
I10
99213
18
M39.0
99213
19
C61
99213
20
E11.9
99214
99213
Medical decision-
making used for
claim upcoding and
accurate diabetes
mellitus code not
used
