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
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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
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
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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 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. bb
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/
