Your HIM Director has met with you and discussed the internal audit coding results. The findings were as follows:
  • Coding accuracy is at an 85%
  • Up-coding was found in physician office visits and cardiac surgeries
  • Global surgeries were unbundled

Below is a sample of few findings from the audit. Analyze the findings to help determine issues that need to be corrected and propose recommendations in the compliance plan.

INV# DOS

Billed

CPT

Documented

DX

Comments

CPT

DX
501120 03/07/1699212

272.0 250.00

401.0

99213

272.0

250.00

401.1

Documentation supports a higher level of service than selected by the provider. Per 1997 guidelines – the status of three chronic conditions – extended HPI. The history level and the MDM both supported the higher level of service.
50435403/15/01699213529.9 V70.0 V03.8999213529.9 V03.89Pass.

V70.0 should not be linked to 99213. It should only be used when a routine examination or counseling is performed.

51829504/15/1699213 71020465.899213
71020
465.8Pass
51866904/18/1699213-25 96372 J0702477.999213-25 96372
J0702
477.9Pass
51867004/18/1699214

401.1 311 272.4

99214Pass
52331004/28/16401.1 274.9 790.69921399213401.1 274.9 790.6Documentation does not support the level of service selected by the provider. All three of the key components support a lower level of service. The CC and HPI are related to HTN–ROS and Exam only address areas related to the HTN.
53099405/18/1699214 71020

786.2 110.1

99214
71020
786.2 110.1Pass
53337205/25/1699214 71020780.60 788.42 99214
71020
780.60 788.42Pass
54934407/06/1699213719.4199213719.41Pass
55044707/08/1699213239.299212239.2Documentation supports a lower level of service than selected by provider. All three key components support the lower level.
55435708/15/16

51045

C1875

N32.951045N32.9Documentation does not support HCPCS Level II code selected by provider. Cannot bill for stent. Review guidelines for global package.
Based on the textbook and other readings, develop a staff development training plan and presentation on a coding compliance plan for your coding department. (You should be familiar with these from previous modules!) Your HIM Director has asked you to give a presentation to the coding staff during the hour long monthly education meeting that you hold regularly. Make sure to consider internal and external coding requirements, regulations and guidelines. Your project should include a detailed outline of your training and a PowerPoint presentation.
Make sure to consider and include the following in your presentation:
  • What are the findings of the audit?
  • What implementations need to be done due to audit findings?
  • Propsed recommendations after learning the findings of the audit?
  • What are the Internal and external coding requirements
  • Be sure to educate the employees and include information on the purpose and function of International Classification of Diseases. Why are these codes so important? Who Developed ICD and why?
  • Identify the development, regulations, and guidelines for ICD-10-CM.
  • Your project should include a detailed outline of your training and a PowerPoint presentation.
  • Identify the purpose of an internal and external audit and describe the difference between the two audits.
  • Identify and explain how SNOMED CT plays a role within the audits and electronic health records.

Another Source: Defining the Core Clinical Documentation Set for Coding Compliance, AHIMA.

Report Audit Results to Educate. (September 1, 2013). Retrieved from AAPC Advancing the Business of Healthcare on January 1, 2017. AAPC.

 

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