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HIM 360 Module Four Audit Summary Report Template
Detailed Analysis: SNHU Medical Clinic
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
