HIM 360 Module Four Summary Report

HIM 360 Module Four Audit Summary Report Template Detailed Analysis: Internal Medicine Clinic Reviewer: Asma Attaoui Date of Review: 05/27/2023 Number of Reports Reviewed: 20 reports. Provider Audit Score: %70 accuracy rate For my insurance audit, I selected the Internal Medicine provider, and within it, I picked two physicians, physician #1 and physician #2. Each physician provided me randomly with 10 charts, and I reviewed the CPT codes, diagnoses codes, charges, and errors. There were a total of 20 audit reports, which included 10 charts from each physician. There were four charts out of ten that were miscoded when auditing physician #1. Upcoding claims based on medical decision-making was responsible for three of these errors, and assigning new patient codes to existing patients was responsible for the fourth error. In physician #2's audit, two charts out of ten were coded incorrectly. One of the errors involved upcoding the claim based on medical decision-making, and the other involved not using the correct diabetes mellitus code. Provider #1 over-coded encounters 3, 8, and 10. The correct code should have been 99213, but they were assigned 99214, resulting in an insurance overcharge. Physician #1 made a fourth mistake by assigning a new patient code 99202 to an existing patient. Instead of 99202, the correct code should be 99212. Among the ten error codes for physician #2, there were only two. In both encounters 12 and 20, the correct code should have been 99213, but both were coded 99214. Of a total of 20 charts, six charts from both physicians were incorrectly coded. As a result, the accuracy rate will be 70%. Out of auditing 20 charts, assigning CPT codes of new patient to existing patients only Page 1 of 5

happened once, which will make it %5It is possible, however, that the number could be higher if the audit covers a large number of charts. For each over-coded claim, the insurance was overcharged $64, and when assigning new CPT codes to existing patients, the insurance was overcharged $57. Most cases of coding inaccuracy occur when claims are coded based on medical decision-making and when diabetes mellitus codes are used incorrectly.  Looking at the entire Internal Medicine Clinic audit report that was conducted in the last 90 days of 2019, the results are not good. An audit was conducted on 60 charts selected at random from different physicians in the clinic. Out of 60 charts, 18 were coded incorrectly, resulting in an overall accuracy rate of 70 percent. As indicated by the Inspector General's office, this will cause some negative consequences for the clinic since the goal is to achieve at least a 95% coding accuracy rate.  That's why coders should make sure that all claims are double checked before submitting them.  To overcome these coding challenges, the Internal Medicine Clinic must take action to improve the accuracy rate and avoid any serious consequences. This includes losing accreditation or facing legal penalties. First, the clinic should talk to coding teams and compliance departments, announce the issue, and discuss the risks if things don't change. Coders always need to ensure that their codes are appropriate for the services the clinic provides. Staff should be provided with education and learning tools to improve their performance. Furthermore, I recommend that the practice conducts random audits on its own to monitor improvement progress and staff performance. In this way, errors can be caught and fixed before official audits are conducted. Page 2 of 5

Present on Admission Documented Error Encounter # / Column A Code/Column Diagnosis Code, or N/A Code / Column C Correct Code / Column C or J, Depending on Whether There Is an Error Identified Errors in Documentation / Column J 1 M54.9 99214 2 R15.9 99213 3 R03.0 99214 99213 Claim upcoded based on medical decision making. 4 R73.09 99213 5 E11.65 99202 99212 New patient codes cannot be used if patient has been seen in hospital by provider or other provider in same group 6 Z01.810 99213 7 I49.9 99213 8 E11.9 99214 9 E11.65 99214 22913 Claim upcoded based on medical decision making and not using correct diabetes mellitus codes for manifestations 10 D64.9 99214 99213 Claim upcoded based on medical decision making Physician: #2 Date of Review: 05/27/2023 Reviewer: Asma Attaoui Number of Reports Reviewed : 10 Reports. Patient Diagnosis Present on Admission CPT Billed CPT Documented Status: Correct or Error Page 4 of 5

Encounter # / Column A Code/Column Diagnosis Code, or N/A Code / Column C Correct Code / Column C or J, Depending on Whether There Is an Error Identified Errors in Documentation / Column J 11  I10 99213  12 I10 99214 99213 Claim upcoded based on medical decision making.  13 J01.00 99214  14 E11.40 99213  15 R74.9 99213  16 J32.9 99213  17 I10 99213  18 N39.0 99213  19 C61 99213 20 E11.9 99214 99213 Claim upcoded based on medical decision making and not using correct diabetes mellitus codes for manifestations. Page 5 of 5