5-2 Final Project Milestone Two: Draft of Compliance and Recommendations Previous Next Instructions Submit the draft of compliance and recommendations (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. A description of the compliance plan (see example) should be presented in this paper, including any positive, negative, or neutral results having a compliance plan presents for a facility. A section of the facility's compliance document was presented in the document. To completely understand how the OIG evaluates a situation identified by an audit, refer to the OIG Compliance Program for Individual and Small Group Physician Practices document. Describe the phases of evaluation by the OIG after a serious deficiency is found in an audit if a facility has a functioning compliance plan as part of its operational documents. For additional details, please refer to the Milestone Two Guidelines And Rubric document, the Segment Of Compliance Plan document, and the Final Project Guidelines And Rubric document. HIM 360 Milestone Two Guidelines and Rubric Submit the draft of compliance and recommendations (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. A description of the compliance plan (see Segment of Compliance Plan example document) should be presented in this paper including any positive, negative, or neutral results that having a compliance plan presents for a facility. A section of the facility’s compliance document was presented in the document. To completely understand how the OIG evaluates a situation identified by an audit, refer to the OIG Compliance Program for Individual and Small Group Physician Practices document. Describe the phases of evaluation by the OIG after a serious deficiency is found in an audit if a facility has a functioning compliance plan as part of its operational documents. Give some suggestions about what would make the compliance plan more viable for the facility. How can the administration be assured the facility understands the requirements of the compliance document? Provide the effects of new governmental requirements with meaningful use and other quality measures; include any educational or additional training that may be needed for the facility staff to complete these new requirements. Review the information found in the Qualified Clinical Data Registry Participation Made Simple document. After reviewing this information, describe possible avenues the providers may take to remain compliant with the governmental regulations and still provide the care that patients need. Explain any issues the staff may have in complying with the new requirements. The work you completed in the Module Four audit activity and summary report will be used to submit this milestone. Specifically, the following critical elements must be addressed: III. Compliance A. Why is the compliance program important? Are there any specific benefits associated with having a formal compliance program? Be sure to support your answers. B. Does the entity have a formal compliance program that is appropriate for their clinic type? Analyze the compliance program that is either already instituted or necessary, according to OIG classifications. C. Do any changes need to be addressed to improve the usefulness of the compliance program? Why or why not? If yes, what are these changes? If no, why do you think this is? IV. Recommendations A. Justify what information may need adjustment to improve and enhance the coding process at this enterprise. Consider where education may be needed to better understand the coding process. B. Recommend changes in the documentation processes to accommodate the Systematized Nomenclature of Medicine (SNOMED) process. Be sure to justify why these changes would help integrate the SNOMED process. C. Does the meaningful use segment accurately reflect the provider’s patient population? Why or why not? Include logical support for your answers. D. Recommend the training for medical staff necessary to attain the industry standards for meaningful use requirements. Consider what industry standards have changed in recent years. Remember to include support for your recommendations. E. What additional technology would you recommend to improve the functions of the current processes in the clinic? Why? Consider which technology this would be supplementing or replacing. F. What additional resources may be needed for the new technology? Budget concerns? Staffing issues? Programming and training? Provide logical reasoning for why these resources would be necessary. G. 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. Guidelines for Submission: This milestone should be submitted as a 5- to 6-page Microsoft Word document written in APA format. Use double spacing, 12-point Times New Roman font, and one-inch margins. All references should be cited in APA format. Critical Elements Compliance: Importance Compliance: Entity Compliance: Changes Exemplary (100%) Meets “Proficient” criteria and provides concrete examples of the benefits of having a formal 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 changes demonstrate a true understanding of the compliance program Proficient (85%) Analyzes the importance and benefits of a compliance program, providing support for analysis Needs Improvement (55%) Analyzes the importance and benefits of 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 Value 10 Thoroughly analyzes the type of formal compliance program that would be appropriate at this specific entity Analyzes the type of formal compliance program that would be appropriate at this entity but analysis is not thorough Does not analyze the type of formal compliance program that would be appropriate at this specific entity 9 Analyzes changes that need to be addressed to improve the usefulness of the compliance program, providing strong and logical reasoning to support analysis Analyzes changes that need to be addressed to improve the usefulness of the compliance program, but reasoning is weak or illogical Does not analyze changes that need to be addressed to improve the usefulness of the compliance program 9 Recommendations: Justify Meets “Proficient” criteria and identifies where education may be needed to better understand the coding process Logically justifies what information may need to be adjusted to improve and enhance the coding process at this enterprise Recommendations: Changes Meets “Proficient” criteria and recommendations demonstrate a nuanced understanding of integrating SNOMED into currently standing documentation processes Meets “Proficient” criteria and explains how meaningful use is used to improve patient outcomes Recommends changes in the documentation process to accommodate the SNOMED process, including justification of recommendations Recommendations: Training Meets “Proficient” criteria and identifies the industry standards that have changed Recommends training for medical staff necessary to attain the industry standards for meaningful use requirements, including support for recommendations Recommendations: Technology Meets “Proficient” criteria and identifies the current technology that may be deficient Recommends additional technology that may be necessary for the current processes, logically justifying recommendations Recommendations: Meaningful Use Assesses the meaningful use segment, logically justifying if it accurately reflects the provider’s patient population Justifies what information may need to be adjusted to improve and enhance the coding process at this enterprise, but justification is illogical, weak, or cursory Recommends changes in the documentation process to accommodate the SNOMED process, but justification of recommendations is illogical, cursory, or weak Does not justify what information may need to be adjusted to improve and enhance the coding process at this enterprise 9 Does not recommend changes in the documentation process to accommodate the SNOMED process 9 Assesses the meaningful use segment, but justification of whether it reflects the provider’s patient population is illogical or inaccurate Recommends training for medical staff necessary to attain the industry standards for meaningful use requirements, but recommendations would not help staff meet industry standards or support provided is illogical, weak, or cursory Recommends additional technology that may be necessary for the current processes, but recommendations will not improve functions of the current processes or justifications for recommendations are illogical, weak, or cursory Does not assess the meaningful use segment 9 Does not recommend training for medical staff necessary to attain the industry standards for meaningful use requirements 9 Does not recommend additional technology that may be necessary for the current processes 9 Recommendations: Resources Meets “Proficient” criteria and assessment considers best practices in attaining additional resources Comprehensively assesses any additional resources that may be needed for the new technology, using logical reasoning to support why resources are necessary Recommendations: Evaluation Meets “Proficient” criteria and makes possible recommendations for the modifications or upgrades in workflow Submission is free of errors related to citations, grammar, spelling, syntax, and organization and is presented in a professional and easy-to-read format Recommends either modifying or upgrading the workflow process and supports choice Articulation of Response Submission has no major errors related to citations, grammar, spelling, syntax, or organization Assesses any additional resources that may be needed for the new technology, but assessment is not comprehensive or reasoning provided as support is illogical, weak, or missing Recommends either modifying or upgrading the workflow process and supports choice but support is illogical, weak, or cursory Submission has major errors related to citations, grammar, spelling, syntax, or organization that negatively impact readability and articulation of main ideas Does not assess any additional resources that may be needed for the new technology 9 Does not recommend either modifying or upgrading the workflow process 10 Submission has critical errors related to citations, grammar, spelling, syntax, or organization that prevent understanding of ideas 8 Earned Total 100% HIM 360 Module One Case Study Guidelines and Rubric Overview: As part of the coding compliance at Southern New Hampshire University, the providers’ charts are audited annually. This step has been completed for you. To perform this task for 2014, a report was created for each provider using the previous 90 days’ encounters. Ten charts were randomly selected using the evaluation and management codes for new and established patients’ office visits. The codes for new patients are 99201, 99202, 99203, 99204, 99205, and codes for established patients are 99211, 99212, 99213, 99214, and 99215. After the report was created, ten charts were randomly selected for each provider. The medical documentation was then copied or printed and delivered to the auditor for evaluation. The auditor reviewed the documentation to determine if the appropriate code was used for billing to the payer. The results of the audit performed for the fourth quarter for the providers of the Hospital Clinic and the Internal Medicine Clinic have been provided for you as examples to use in this exercise. Any exceptions found during the audits have been noted in the spreadsheets. The results of these example audits have been summarized on a second, yellow tab “Summary”. This summary portion contains only the encounters that did not meet the required documentation levels for billing the selected code. The insurance payers who paid these affected claims must be notified and a corrected claim will be submitted to the payers. This summary includes the encounter number, the date of service, the incorrect code billed and the code that is supported by the documentation, the diagnosis code(s), the amount of the payment, the insurance payer, the provider number, and the reason the documentation does not support the billed code. The spreadsheet also indicates the amount of payment differences for the actual payment received and the amount that should have been received. Prompt: For this assignment, you will complete the “Summary” tab for the Family Practice Charges Claims for Audit 2014 Template spreadsheet. Follow these steps as you work through this assignment: 1. Review the “Initial Claims” or “Initial Encounter” green tab found in the Internal Medicine 2014 spreadsheet and the Hospital Clinic Claims for Audit 2014 spreadsheet. 2. Then, review the yellow “Summary” tabs in both spreadsheets. Make sure you understand the relationship between the two tabs in each spreadsheet. 3. Using the, Internal Medicine 2014 Sample spreadsheet and the Hospital Clinic Claims for Audit 2014 Sample spreadsheet as examples, complete the table in the “Summary” tab in the Family Practice Charges Claims for Audit 2014 Template spreadsheet. 4. Copy or transfer the information from the Initial Claims tab of the Family Practice Charges Claim for Audit 2014 spreadsheet to the Summary tab. 5. You can find the charges related to the E/M codes of question on the Initial Claims tab of the Family Practice Charges Claim for Audit 2014 spreadsheet. 6. Complete a detailed analysis of the audit results, also within the “Summary” tab in the Family Practice spreadsheet. Include the following in your analysis (roughly a paragraph): a. A summary of the audit process and details, including the steps that were done for you here and information about which year is being audited, how many charts were selected, and so on. *HINT* All of this information can be found at the top of this document. b. A summary of the audit results. What does the audit show? c. Make a suggestion for improvement. How could the Family Practice Clinic reduce errors in the future? Specifically, you will be graded on the following critical elements: • • Audit Summary: Complete the yellow “Summary” tab in the Family Practice Charges Claims for Audit 2014 Template. Analysis: Complete a detailed analysis for the Family Practice Charges Claims for Audit 2014 to include: summary of audit and process details; summary of audit results; suggestions for improvement Guidelines for Submission: This case study will be submitted using the completed spreadsheet summary for the Family Practice Charges Claims for Audit 2014 Template. Any outside references should be cited in APA format. Critical Elements Audit Summary Exemplary (100%) Meets “Proficient” criteria and uses examples to complete the spreadsheet Proficient (85%) Completes the spreadsheet for the Family Practice Charges Claims for Audit 2014 Template Analysis Meets “Proficient” criteria and uses clear and relevant examples to support analysis Completes a detailed analysis for the remaining clinics from the information found in the spreadsheet Articulation of Response Submission is free of errors related to citations, grammar, spelling, syntax, and organization and is presented in a professional and easy-to-read format Submission has no major errors related to citations, grammar, spelling, syntax, or organization Needs Improvement (55%) Completes the spreadsheet for the Family Practice Charges Claims for Audit 2014 Template, but is inaccurate Completes a detailed analysis for the remaining clinics from the information found in the spreadsheet, but does not use specific details Submission has major errors related to citations, grammar, spelling, syntax, or organization that negatively impact readability and articulation of main ideas Not Evident (0%) Does not complete the spreadsheet for the Family Practice Charges Claims for Audit 2014 Template Does not complete a detailed analysis for the remaining clinics from the information found in the spreadsheet Submission has critical errors related to citations, grammar, spelling, syntax, or organization that prevent understanding of ideas Value 45 Earned Total 100% 45 10 HIM 360 Module One Case Study Guidelines and Rubric Overview: As part of the coding compliance at Southern New Hampshire University, the providers’ charts are audited annually. This step has been completed for you. To perform this task for 2014, a report was created for each provider using the previous 90 days’ encounters. Ten charts were randomly selected using the evaluation and management codes for new and established patients’ office visits. The codes for new patients are 99201, 99202, 99203, 99204, 99205, and codes for established patients are 99211, 99212, 99213, 99214, and 99215. After the report was created, ten charts were randomly selected for each provider. The medical documentation was then copied or printed and delivered to the auditor for evaluation. The auditor reviewed the documentation to determine if the appropriate code was used for billing to the payer. The results of the audit performed for the fourth quarter for the providers of the Hospital Clinic and the Internal Medicine Clinic have been provided for you as examples to use in this exercise. Any exceptions found during the audits have been noted in the spreadsheets. The results of these example audits have been summarized on a second, yellow tab “Summary”. This summary portion contains only the encounters that did not meet the required documentation levels for billing the selected code. The insurance payers who paid these affected claims must be notified and a corrected claim will be submitted to the payers. This summary includes the encounter number, the date of service, the incorrect code billed and the code that is supported by the documentation, the diagnosis code(s), the amount of the payment, the insurance payer, the provider number, and the reason the documentation does not support the billed code. The spreadsheet also indicates the amount of payment differences for the actual payment received and the amount that should have been received. Prompt: For this assignment, you will complete the “Summary” tab for the Family Practice Charges Claims for Audit 2014 Template spreadsheet. Follow these steps as you work through this assignment: 1. Review the “Initial Claims” or “Initial Encounter” green tab found in the Internal Medicine 2014 spreadsheet and the Hospital Clinic Claims for Audit 2014 spreadsheet. 2. Then, review the yellow “Summary” tabs in both spreadsheets. Make sure you understand the relationship between the two tabs in each spreadsheet. 3. Using the, Internal Medicine 2014 Sample spreadsheet and the Hospital Clinic Claims for Audit 2014 Sample spreadsheet as examples, complete the table in the “Summary” tab in the Family Practice Charges Claims for Audit 2014 Template spreadsheet. 4. Copy or transfer the information from the Initial Claims tab of the Family Practice Charges Claim for Audit 2014 spreadsheet to the Summary tab. 5. You can find the charges related to the E/M codes of question on the Initial Claims tab of the Family Practice Charges Claim for Audit 2014 spreadsheet. 6. Complete a detailed analysis of the audit results, also within the “Summary” tab in the Family Practice spreadsheet. Include the following in your analysis (roughly a paragraph): a. A summary of the audit process and details, including the steps that were done for you here and information about which year is being audited, how many charts were selected, and so on. *HINT* All of this information can be found at the top of this document. b. A summary of the audit results. What does the audit show? c. Make a suggestion for improvement. How could the Family Practice Clinic reduce errors in the future? Specifically, you will be graded on the following critical elements: • • Audit Summary: Complete the yellow “Summary” tab in the Family Practice Charges Claims for Audit 2014 Template. Analysis: Complete a detailed analysis for the Family Practice Charges Claims for Audit 2014 to include: summary of audit and process details; summary of audit results; suggestions for improvement Guidelines for Submission: This case study will be submitted using the completed spreadsheet summary for the Family Practice Charges Claims for Audit 2014 Template. Any outside references should be cited in APA format. Critical Elements Audit Summary Exemplary (100%) Meets “Proficient” criteria and uses examples to complete the spreadsheet Proficient (85%) Completes the spreadsheet for the Family Practice Charges Claims for Audit 2014 Template Analysis Meets “Proficient” criteria and uses clear and relevant examples to support analysis Completes a detailed analysis for the remaining clinics from the information found in the spreadsheet Articulation of Response Submission is free of errors related to citations, grammar, spelling, syntax, and organization and is presented in a professional and easy-to-read format Submission has no major errors related to citations, grammar, spelling, syntax, or organization Needs Improvement (55%) Completes the spreadsheet for the Family Practice Charges Claims for Audit 2014 Template, but is inaccurate Completes a detailed analysis for the remaining clinics from the information found in the spreadsheet, but does not use specific details Submission has major errors related to citations, grammar, spelling, syntax, or organization that negatively impact readability and articulation of main ideas Not Evident (0%) Does not complete the spreadsheet for the Family Practice Charges Claims for Audit 2014 Template Does not complete a detailed analysis for the remaining clinics from the information found in the spreadsheet Submission has critical errors related to citations, grammar, spelling, syntax, or organization that prevent understanding of ideas Value 45 Earned Total 100% 45 10 HIM 360 Milestone One Guidelines and Rubric Submit a draft of evaluation (Section II). You will complete an audit of the information provided in the case study. You will identify educational needs, process, and workflow concerns through the documents in the case study. After completing the evaluation of the final audit results, you will compile a list of providers that need additional education based on the results of the audit. To ensure you are including all of the information needed for the evaluation, consider the answers of the following questions:    What information appears to be causing the providers the main issues? Does it appear to be an individual issue or could there have been a change in a process within the office? If it was a change, how should this change be addressed? A complete audit will identify many areas in the office, including both the process of the office and the workflow found in the office. A thorough audit allows the auditor to present, from a neutral stance, possible solutions to issues that were identified in the audit. In this milestone, you will identify any processes or technology that may need upgrading.   If the technology is current, then it is important to identify any educational changes for the staff that will help to improve the workflow of the facility. If the technology is not current, then identify what was found in the audit to indicate an upgrade is necessary and what challenges the staff will face learning the new technology. This draft will give the outcome of the provider chart audit and what the outcome means to the status of the accounts represented by the charts. This paper will describe the processes that may need to be addressed because of findings in the audit; any findings associated with the workflow of the office or educational deficiencies that may need to be addressed should be identified in the document. Any positive or negative aspects of the EHR should be addressed in this portion of the paper. The work you completed in the Module One discussion, Module One case study, and Module Two activity will be used to submit this milestone. Specifically, the following critical elements must be addressed: 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. B. Are there any charts that need to be addressed because the encounter was overcoded and the provider received payment on the higher code? Are there processes in place to correct these types of charts? If so, what would the process be to address the overcoding? If not, what processes need to be developed for correcting charts and providing education to the provider? C. D. E. What processes were evaluated because of changes in policy? Do these processes need to be adjusted? Do any of these processes need to be completely rewritten to meet criteria for the guidelines? Provide support for your answers. Is there a proper workflow in the clinic? Is there any additional education needed for the clinic staff? Why or why not? Provide support for your answer. Is the EHR system sufficient to meet the needs of the clinic? Does it provide the necessary criteria for reporting the quality measures for patients? Is it user-friendly and dependable to maintain the entered data? If not, what adjustments could be made to improve the system? Is it a matter of education for the staff, or is it a matter of the system not being the appropriate system for the clinic? Guidelines for Submission: This milestone should be a 4–5 page Microsoft Word document written in APA format. Use double spacing, 12-point Times New Roman font, and one-inch margins. All references should be cited in APA format. Critical Elements Evaluation: Outcome Exemplary (100%) Meets “Proficient” criteria and identifies specific deficiencies in provider audits Evaluation: Charts Meets “Proficient” criteria and identification of process(es) indicates a keen understanding of overcoding Meets “Proficient” criteria and explains why the changes in coding policy were necessary Evaluation: Processes Proficient (85%) Assesses the outcomes of provider chart audits and provider education needs, providing support for the assessment Comprehensively assesses overcoding in charts Needs Improvement (55%) Assesses the outcomes of provider chart audits and provider education needs, but assessment or support is cursory or weak Assesses overcoding in charts, but assessment is not comprehensive Not Evident (0%) Does not assess the outcomes of provider chart audits and provider education needs Value 18 Does not assess overcoding in charts 18 Comprehensively assesses the processes that were evaluated because of changes in policy, providing support for the assessment Assesses the processes that were evaluated because of changes in policy, but assessment is not comprehensive, or support provided for assessment is weak Does not assess the processes that were evaluated because of changes in policy 18 Evaluation: Workflow Evaluation: EHR System Articulation of Response Meets “Proficient” criteria and describes the type of education that would be necessary or explains other processes that would be of value if education would not improve the process Meets “Proficient” criteria and evaluation of EHR system demonstrates a nuanced insight into the necessary criteria for reporting quality measures Submission is free of errors related to citations, grammar, spelling, syntax, and organization and is presented in a professional and easy-toread format Evaluates workflow in the clinic, providing support for evaluation Evaluates workflow in the clinic, but support for evaluation is illogical or weak Does not evaluate workflow in the clinic 18 Comprehensively evaluates the appropriateness of the current EHR system for the clinic Evaluates the appropriateness of the current EHR system for the clinic, but evaluation is not comprehensive Does not evaluate the appropriateness of the current EHR system 18 Submission has no major errors related to citations, grammar, spelling, syntax, or organization Submission has major errors related to citations, grammar, spelling, syntax, or organization that negatively impact readability and articulation of main ideas Submission has critical errors related to citations, grammar, spelling, syntax, or organization that prevent understanding of ideas 10 Earned Total 100%
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