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The following information is a small portion of the coding compliance program that will affect the auditing of the charts by the compliance department

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The following information is a small portion of the coding compliance program that will affect the auditing of the charts by the compliance department. Coding Compliance Program for SNHU: 1. Our coding compliance is based on the values of our organization. These values include our responsibilities: ? ? ? ? To the patients—to provide the best, most effective, and safest treatment available To our employees—to provide for the safety of our employees in the work environment; to make sure our employees are properly trained to perform their tasks in a manner that is conducive to reaching the most accurate results possible To our stakeholders—to make sure we are using our resources wisely and being good stewards of the resources provided for the use of the organization; to continually monitor the effectiveness of programs to stay current with the rules, regulations, and guidelines that impact the daily operations of our organization To the community we serve—to evaluate the needs of the community and to ensure our organization is providing the services needed by the members of the community 2. Our organization uses coding guidelines that have been established by the American Medical Association (AMA) and adopted by the Centers for Medicare and Medicaid Services (CMS). These guidelines include the assignment of: ? ? ? ? Diagnosis codes found in the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-10-CM) HCPCS Level I codes found in the Current Procedural Terminology (CPT) codes published annually by the AMA HCPCS Level II, developed, updated, and maintained by the federal government 1997 Documentation Guidelines for Evaluation and Management Services Our staff members are to apply the guidelines found in the above documents to the coding of documentation that is relevant in the treatment of the patients of our organization. 3. An effective coding program must be continually evaluated and monitored to ensure its effectiveness. The goals of the coding compliance program are: ? ? ? ? ? Achieving 97% accuracy in the coding of claims Continually striving to reduce billing and claim errors Achieving 100% of all coding staff attaining certification status Meeting the education requirements of our coding staff Providing training to ensure coding staff has sufficient opportunities to acquire the continuing education units (CEUs) required to maintain their certified status 1 4. To reach the above goals, the following process will be used by the staff of the compliance department: ? ? ? ? ? ? ? ? ? All physicians will be audited annually and receive a score on the audit. If the score is not 100%, the physician will be educated in the area(s) of deficiency. If the score is 100%, the physician will be notified and given a report of the audited charts. The charts audited will be a random selection from the encounters found in the previous 90 days. The codes to be audited in a general audit are the ICD-10-CM diagnoses codes and Evaluation and Management (CPT) codes used by the providers. o These codes are 99201–99215. All new physicians will receive a New Provider Orientation package from the Compliance Department. Additional information may be used by the compliance department to determine the effectiveness of the coding within each clinic. An example of this is the use of bell curves to identify providers which are out of the normal range of codes. A report will be submitted to the compliance committee to provide for evidence of the effectiveness or lack of effectiveness of the compliance department. Areas to be covered by the education staff to improve the billing and claim errors of the clinics will be identified. 5. Auditing charts are a very important part of the compliance department. After the charts are audited, it is possible there may be errors that need to be corrected. The following is the process to be used to correct errors found in the audit: ? ? ? ? ? Since the claims are audited through a post-payment review, if the code billed is not supported by the documentation in the chart, a correction will have to be made by filing a corrected claim to the payer. This may result in a reduction in payment or an increase in payment; both ways must be corrected. The patient’s encounter must reflect the difference in the coding. The file must show a voided incorrect code and a posted correct code. The corrected claim will be then be filed to the payer. If the payer will process the corrected claim, reversing the incorrect payment, and then paying the correct claim, there will be no need to issue a check to correct any overpayments. If the payer will not recoup any overpaid monies, a check must be issued to the payer for the overpayment. It is extremely important this process be completed within 45 days of the identification of the error. The above is the section of the compliance program that will be used to determine what information is needed to evaluate the coding compliance of our facility. There are some topics covered simply as a note in the modules, such as giving the names of new providers to the organization. Since the process above indicates a New Provider Orientation package will be given to the new providers, the students will simply identify this in their reports. However, on issues such as receiving or not receiving a 100% on the audits, the students will need to identify which providers did or did not attain the 100% goal and identify where education is needed. Students will not be required to perform the actual audits. They will be provided with information gained from an audit of charts. From this information, they will need to determine why the provider did not meet the desired level of code. This will be the information used in their final monthly compliance report. 2 HIM 360 Final Project Guidelines and Rubric Overview The final project for this course is the creation of a monthly compliance report. The final product represents an authentic demonstration of competency because today’s healthcare entities actively seek employment candidates who understand the coding process and can competently work within the documentation and compliance regulations. You will be using the Module One Case Study information as you work on your final project. The project is divided into two milestones, which will be submitted at various points throughout the course to scaffold learning and ensure quality final submissions. These milestones will be submitted in Modules Three and Five. The final product will be submitted in Module Seven. In this assignment, you will demonstrate your mastery of the following course outcomes: • • • • • Evaluate the efficiency of coding policies for their implications on employee training [HCM-360-01] Assess healthcare documentation by utilizing industry standard technology for its relevance in the auditing and health data standard reporting processes [HCM-360-02] Recommend workflow policy adjustments for improving technology processes [HCM-360-03] Evaluate electronic health record systems through audits and reporting for information placement and system updates [HCM-360-04] Analyze ethical violations for maintaining compliance with healthcare rules and regulations [HCM-360-05] Prompt As the compliance manager of the SNHU Medical Clinic, it is your responsibility to identify any deficiencies in the coding process for the encounters in the clinic. You will select encounters to be audited to determine the percentage of charts that are documented accurately when comparing the documentation to the selected code(s). This achieved rate will be recorded and reported back to the provider. If this rate is less than the agreed percentage, the provider will receive education from your department on the identified deficiencies. A monthly report will be provided to the appropriate compliance departments or director of the department. Your monthly compliance report should answer the following prompt: What issues have been identified as needing improvement either in the form of education or technology improvement to meet the goals for the SNHU Medical Clinic? A description of the compliance plan (see Segment of Compliance Plan Example, linked in the Final Project Submission assignment in Module Seven of your course) should be presented in this paper, including any positive, negative, or neutral results that having a compliance plan presents for a facility. 1 Specifically, you must address the critical elements listed below. I. Preface A. Compose a preface for the monthly compliance report after completing the separate elements below. Be sure to include the focus of the report and frame it for your intended audience. II. Evaluation A. What is the overall outcome of the provider chart audits? Are there any providers that need extensive education based on the outcomes? Provide support for your answers. [HCM-360-02] B. There are charts in the case study where the documentation did not support the diagnosis and evaluation and management (E/M) coding that was billed for the encounter. What coding guidelines and/or policies should have been followed when establishing the diagnosis and E/M code? [HCM-360-02] C. How would you implement or revise the review processes of clinical documentation for prospective, concurrent, and retrospective reviews? Be sure to include the workflow and training opportunities for staff in your response. [HCM-360-04] D. Does the EHR system provide the necessary criteria for reporting the quality measures for the patients? Is this an appropriate system for the clinic, or should adjustments be made to improve the user experience and dependability? Support your answer. [HCM-360-04] III. Compliance A. What is the importance of the compliance program? Are there any specific benefits associated with having a formal compliance program? What consequences are there to not having a compliance program? Be sure to support your answers. [HCM-360-05] B. Analyze the formal compliance program currently in place. Is that appropriate for the clinic type, according to OIG classifications? [HCM-360-05] C. What are the consequences if the plan is not adhered to, and how should the organization monitor in order to remain compliant? Do any changes need to be addressed to improve the usefulness of the compliance program? Why or why not? Support your answer. [HCM-360-05] IV. Recommendations A. Recommend what may need to be adjusted to improve and enhance the coding process at this enterprise. Where is additional education needed to better understand the coding process? Support your answer. [HCM-360-01] B. Recommend improvements in the clinical documentation processes based on evaluation of the workflow processes to accommodate the Systematized Nomenclature of Medicine (SNOMED) process. Be sure to justify why these changes would help. [HCM-360-01] C. In reference to quality measures, do the improvements recommended accurately reflect the provider’s patient population regarding SNOMED? Why or why not? Support your answer. [HCM-360-02] D. Recommend the training for medical staff necessary to attain the industry standards to meet healthcare data reporting requirements. Consider how industry standards have changed in recent years. Support your answer. [HCM-360-01] E. What is fraud and abuse? What should the auditors do/what directions to follow if they suspect fraud or abuse? [HCM-360-05] 2 F. With consideration to which technology would need supplementing or replacing, what additional technology would you recommend to improve the functions of the current processes in the clinic? [HCM-360-03] G. What additional resources may be needed for implementing your technology recommendation? Consider resources such as budget, staffing, and training in your response. [HCM-360-03] H. What intervals are audits scheduled, and are they sporadically scheduled? Who does the organization report issues to if fraud and abuse is detected? [HCM-360-05] I. After evaluation, would you recommend modifying the workflow process in the clinic or would an upgrade be sufficient? Why? Be sure to support your choice. [HCM-360-03] V. Conclusion A. What is the overall status of the coding program of this entity? Support your answer. [HCM-360-01] B. Overall, did this entity maintain compliance with healthcare rules and regulations? Support your answer with evidence from the providers’ charts. Consider any major ethical issues that may have been discovered during your analysis. [HCM-360-05] C. Were there any significant training issues identified in the audit? What preventions are in place to prevent training deficits from arising? [HCM360-01] D. Does the technology being used in the clinic support the reporting of the healthcare data reporting requirement guidelines? If not, what recommendations can be made to improve the technology? [HCM-360-02] Milestones Milestone One: Draft of Evaluation In Module Three, you will submit a draft of the evaluation section (section II). Complete an audit of the information provided in the case study, identifying educational needs, process, and workflow concerns. After completing the evaluation of the final audit results, compile a list of providers that need additional education. This milestone will be graded with the Milestone One Rubric. Milestone Two: Draft of Compliance and Recommendations In Module Five, you will submit a draft of the compliance and recommendations sections (sections III and IV). This portion of the paper will address the purpose for the compliance document and how this relates to the daily operations of the facility, and describe the phases of evaluation by the OIG after a serious deficiency is found in an audit. This milestone will be graded with the Milestone Two Rubric. Final Submission: Monthly Compliance Report In Module Seven, you will complete the preface and conclusion sections (sections I and V), and submit your final project. It should be a complete, polished artifact containing all of the critical elements of the final product. It should reflect the incorporation of feedback gained throughout the course. This submission will be graded with the Final Project Rubric. 3 Final Project Rubric Guidelines for Submission: Your monthly compliance report must be 10- to 12- pages in length (plus a cover page and references) and must be written in APA format. Use double spacing, 12-point Times New Roman font, and one-inch margins. Include at least seven references cited in APA format. Critical Elements Preface Exemplary (100%) Meets “Proficient” criteria and clearly identifies the purpose or intent of the report Proficient (85%) Composes a preface for monthly compliance report, framed for intended audience, and including focus of the report Assesses the outcomes of provider chart audits and provider education needed, providing support for the assessment Determines the coding guidelines and/or policies that should be followed when establishing the diagnosis and E/M code Evaluation: Outcome [HCM-360-02] Meets “Proficient” criteria and identifies specific deficiencies in provider audits Evaluation: Coding Guidelines [HCM-360-02] Meets “Proficient” criteria and gives detailed support to coding guidelines/policies determined Evaluation: Review Processes [HCM-360-04] Meets “Proficient” criteria and explains how the review processes would impact the workflow Determines how review processes of clinical documentation for prospective, concurrent, and retrospective reviews would be revised or implemented with workflow being considered Evaluation: EHR System [HCM-360-04] Meets “Proficient” criteria and gives justification to response Determines if the EHR system provides the necessary criteria for reporting the quality measures for the patients, and is an appropriate system for the clinic, providing support for evaluation 4 Needs Improvement (55%) Composes a preface for monthly compliance report but is not framed for intended audience or the focus of the report is vague Assesses the outcomes of provider chart audits and provider education needs, but assessment or support are cursory or weak Not Evident (0%) Does not compose a preface for the monthly compliance report Value 5 Does not assess the outcomes of provider chart audits and provider education needs 4.5 Determines the coding guidelines and/or policies that should be followed when establishing the diagnosis and E/M code, but response is not comprehensive Determines how review processes of clinical documentation for prospective, concurrent, and retrospective reviews would be revised or implemented with workflow being considered, but evaluation is not comprehensive, or support provided for evaluation is weak Determines if the EHR system provides the necessary criteria for reporting the quality measures for the patients, and is an appropriate system for the clinic, providing support for evaluation, but evaluation is not comprehensive, or support provided for evaluation is weak Does not determine the coding guidelines and/or policies that should be followed when establishing the diagnosis and E/M code Does not determine how review processes of clinical documentation for prospective, concurrent, and retrospective reviews would be revised or implemented 4.5 Does not determine if the EHR system provides the necessary criteria for reporting the quality measures for the patients 9 9 Critical Elements Compliance: Importance [HCM-360-05] Compliance: OIG Classifications [HCM-360-05] Compliance: Usefulness [HCM-360-05] Recommendations: Enhance the Coding Process [HCM-360-01] Recommendations: Improvements [HCM-360-01] Recommendations: Quality Measures [HCM-360-02] Exemplary (100%) Meets “Proficient” criteria and provides concrete examples of the benefits of having a formal compliance program, and the consequences of not having a compliance program Meets “Proficient” criteria and analysis demonstrates a nuanced understanding of OIG classifications and their application to formal compliance programs Meets “Proficient” criteria, and suggested monitoring plans and changes demonstrate a solid understanding of the compliance program Proficient (85%) Analyzes the importance and benefits of a compliance program, and the consequences of not having a compliance program, providing support for analysis Analyzes the type of formal compliance program that would be appropriate at this specific entity based on OIG classifications Needs Improvement (55%) Analyzes the importance and benefits of a compliance program, and includes consequences of not having a compliance program, but support provided is cursory, weak, or illogical Not Evident (0%) Does not analyze the importance and benefits of a compliance program, and the consequences of not having a compliance program Analyzes the type of formal compliance program that would be appropriate at this specific entity based on OIG classifications, but analysis is weak or illogical Does not analyze the type of formal compliance program that would be appropriate at this specific entity based on OIG classifications 3 Analyzes the consequences if the plan is not adhered to, monitoring plans, and changes that need to be addressed to improve the usefulness of the compliance program Analyzes the consequences if the plan is not adhered to, monitoring plans, and changes that need to be addressed to improve the usefulness of the compliance program, but reasoning is weak or illogical 3 Meets “Proficient” criteria and recommendation includes detailed plan of how education would improve the coding process Meets “Proficient” criteria and recommendations demonstrate a nuanced understanding of integrating SNOMED into currently standing processes Meets “Proficient” criteria and explains how SNOMED is used to improve patient outcomes.