Southern New Hampshire University
HIM 360 Module Four Audit Summary Report Template
Detailed Analysis: SNHU Medical Clinic
Reviewer: Lauretta Krakue
Date of Review: February 25, 2022
Number of Reports Reviewed: 20
Provider Audit Score: 70 %
I selected two physicians and ten charts of each provider for insurance audit purpose. The
elements that are reviewed are CPT Codes, Diagnosis codes, errors and error causes. Out of all
the charts only 6 contained CPT errors.
While reviewing the CPT codes, and diagnosis codes it was observed that physicians upcode for
medical decision-making. It could be because of not coding to maximum specificity leading to
wrong diagnosis codes and missing manifestations documentation. It is common with
Hypertension and Diabetes. This practice leads to revenue loss. It can lead to underpayment or
overpayment and the organization's revenue may diminish or it may have to return the money
with a fine. These errors show that diagnosis is not specific. There is need for more
specifications so that coders can code for maximum specificity.
Another observation is that providers use incorrect CPT codes for existing vs. new patients. Out
of 20 charts there was a single such error. But its frequency could rise when more charts are
examined. A patient cannot be considered a new patient if he or she is seen in the organization
for any service previously. In case of such patients, the codes 99211-99215 must be used. The
registration department must ensure accuracy of these aspects and the workflow from the start.
Coders must double check since E/M coders occasionally use the codes. In the specific context it
is done by providers. However, other units in the organization must be alerted about it.
Provider 1 had most errors which decreased the accuracy rate. He can fix his error by being more
specific and capturing more information in his documentation. It can help coders to select the best code that fits the documentation. Physician 1 also had incorrect patient status CPT code. The
registration should have correct information so that the provider can ascertain whether a patient
is new or existing.
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Southern New Hampshire University
Provide 2 had fewer errors as compared to Provider 1. His errors were relayed to upcoding which
is due to poor documentation of manifestations and not being specific. Such errors may cause incorrect coding, conflict documentation and the use of incorrect CPT codes. The CDI must
inquire providers about specificity to correct coding and improve documentation.
My initial step would be to identifying and reviewing the actual guidelines. Then a meeting with
the providers must be scheduled for addressing the issue. In the meeting I will explain the
documentation process and its benefits. Then training must be provided to providers about the
documentation process and the processes that they use. It can help to mend the incorrect
processes. After one month evaluation will be done to see any improvement. If problems exist
then they would be documented and methods would be found to fix