coding audit

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PPA I OVERVIEW LOCATION: UNIVERSITY CLINIC ASSOCIATES

To complete this activity you are required to read and analyze the case study, “E/M Coding Audit at University Clinic Associates.” The case study includes a sample audit for your use. As a part of this assignment you will write/create a report or presentation for the financial manager of University Clinic Associates with conclusions and recommendations.

 

Requirements

Read the case study about the University Clinic Associates Below:

University Clinic Associates employs over 200 physicians who are on the faculty at the University Hospitals and Clinics. With 20 specialty clinics and over 2000 clinic visits a week, accurate coding and documentation of these encounters is critical to obtaining the correct reimbursement. At present, each clinic is staffed with mostly clerical staff members who do the scheduling of appointments, registration of patients, and data entry from encounter forms for billing purposes.

To assess the current situation, William Murken, the financial manager responsible for the clinics, has hired you (an RHIT with a CCS credential) as a consultant to conduct a coding and documentation audit.

You meet with the staff to go over the records and complete the audit. After you have established a rapport, you remind staff members that accurate diagnostic and procedural coding cannot be achieved without clear and complete health record documentation. There are many instances where documentation omissions, such as the specifics of a service, can affect reimbursement.

Nowhere is this truer, you explain, than in recording Evaluation and Management Services. Virtually every physician performs E/M services. Thus, the impact of coding and documentation on the reimbursement of these services is enormous. When billed services cannot be substantiated using documentation in the health record, the physician may not get paid or may have to refund overpayment.

The staff seems to appreciate your input. One person comments, “This will give us a target as we assign medical codes in the future.”

 

For a copy of your Audit results, see below:

Download the data sheet related to the case study at University Clinic Associates linked below.

Requirements to Include in Your Presentation

Using the above pieces of information, write a complete 1-2 page report or presentation describing your findings to the financial manager. The format used for your presentation can be a Word Document, Power Point Presentation, or Letter/Memo format. Be creative in your presentation to the Financial Manager. Your report must include:

  1. An interpretation and description of the findings in Table 1.
    • Did the clinic over or under charge overall?
    • What is the total amount?
  2. A well written conclusion to the financial manager based on your findings, including examples of the errors found.
    • Which codes were over coded, thus over billed? Which were under coded, thus under billed?
  3. Provide recommendations (being specific) on staffing, education, forms, and design.
    • Provide at least four ideas/changes the clinic can implement to improve the coding. Each idea should be specific and include supporting reasoning for why the change would improve the coding at this clinic.

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