Running Head: MILESTONE ONE
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Milestone One – Draft of Evaluation
HIM360
Southern New Hampshire University
January 27,2022
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Maintaining 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 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). Encounters 5556,5171,
3255, 4884, 6666, 502, and 2426 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 moderate complexity. The audit’s summary section shows that 7
out of 9 charts have a low complexity medical decision-making level. The other two charts
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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. 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
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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. j j
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
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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.
References
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Giannangelo, K. (2019). Healthcare code sets, clinical terminologies, and classification
systems (4th ed.). Chicago, IL: AHIMA, American Health Information Management
Association.
Oachs, P. K., & Watters, A. L. (2016). Health information management: concepts, principles,
and practice (5th ed.). Chicago, IL: AHIMA, American Health Information Management
Association.
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/
