The purpose for the compliance document and how this relates to the daily operations of the facility

Submit the draft of compliance and recommendations (Section 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.
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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 with …
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