HIM 360 Module One Case Study Guidelines and Rubric
Overview: As part of the coding compliance at Southern New Hampshire University, the providers’ charts are audited annually. This step has been completed for
you. To perform this task for 2019, a report was created for each provider using the previous 90 days’ encounters. Ten charts were randomly selected using the
evaluaon and management codes for new and established paents’ oce visits. The codes for new paents are 99201, 99202, 99203, 99204, 99205, and codes
for established paents are 99211, 99212, 99213, 99214, and 99215. Aer the report was created, ten charts were randomly selected for each provider. The
medical documentaon was then copied or printed and delivered to the auditor for evaluation. The auditor reviewed the documentaon to determine if the
appropriate code was used for billing to the payer.
The results of the audit performed for the fourth quarter for the providers of the Hospital Clinic and the Internal Medicine Clinic have been provided for you as
examples to use in this exercise. Any excepons found during the audits have been noted in the spreadsheets. The results of these example audits have been
summarized on a second, yellow tab “Summary”. This summary poron contains only the encounters that did not meet the required documentaon levels for
billing the selected code. The insurance payers who paid these aected claims must be noed and a corrected claim will be submied to the payers. This
summary includes the encounter number, the date of service, the incorrect code billed and the code that is supported by the documentaon, the diagnosis
code(s), the amount of the payment, the insurance payer, the provider number, and the reason the documentaon does not support the billed code. The
spreadsheet also indicates the amount of payment dierences for the actual payment received and the amount that should have been received.
Prompt: For this assignment, you will complete the “S ”ummary tab for the Family Pracce Charges Claims for Audit 2019 Template spreadsheet. Follow these
steps as you work through this assignment:
1. Review the “Inial Claims” or “Inial Encounter” green tab found in the Internal Medicine 2019 spreadsheet and the Hospital Clinic Claims for Audit 2019
spreadsheet.
2. Then, review the yellow “Summary” tabs in both spreadsheets. Make sure you understand the relaonship between the two tabs in each spreadsheet.
3. Using the, Internal Medicine 2019 Sample spreadsheet and the Hospital Clinic Claims for Audit 2019 Sample spreadsheet as examples, complete the table
in the “Summary” tab in the Family Pracce Charges Claims for Audit 2019 Template spreadsheet.
4. Copy or transfer the information from the Inial Claims tab of the Family Pracce Charges Claim for Audit 2019 spreadsheet to the Summary tab.
5. You can nd the charges related to the E/M codes of queson on the Inial Claims tab of the Family Pracce Charges Claim for Audit 2019 spreadsheet.
6. Complete a detailed analysis of the audit results, also within the “Summary” tab in the Family Pracce spreadsheet. Include the following in your analysis
(roughly a paragraph):
a. A summary of the audit process and details, including the steps that were done for you here and informaon about which year is being audited,
how many charts were selected, and so on. *HINT* All of this informaon can be found at the top of this document.
b. A summary of the audit results. What does the audit show?
c. Make a suggestion for improvement. How could the Family Pracce Clinic reduce errors in the future?
