Running Head: MILESTONE ONE
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Milestone One – Draft of Evaluation
HIM360
Southern New Hampshire University
MILESTONE ONE
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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
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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 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
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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.
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References
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/
