MCCG210 Portfolio Project Week 6

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Bryant & Stratton College *

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MCCG210006

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Accounting

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Feb 20, 2024

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MCCG210 Portfolio Project Lona Kiser 9/29/2023 Instructor Ruggiero

Portfolio Project: Audit of Clinical Documentation to Address Poor Documentation and/or Inaccurate Coding within the CMI Introduction Complete and accurate clinical documentation is critical in the healthcare industry. It ensures regulatory compliance, quality patient care, and reimbursement for services rendered. This paper explores the process of preparing for an audit of clinical documentation to address poor documentation and/or inaccurate coding within the Case Mix Index (CMI). Body I. Identifying the Scope and Purpose of the Audit The first step in preparing for the audit is to identify the scope and purpose of the audit. This ensures that the audit objectives are clear, and the areas of focus are determined. The steps for identifying the scope and purpose of the audit are as follows: 1. Define the objectives of the audit: The first step is to determine the objectives of the audit. This will provide a clear understanding of what the audit is trying to achieve and will help in identifying the scope of the audit. 2. Identify the areas of focus: Once the objectives of the audit have been defined, the next step is to identify the areas of focus. This will help in determining the scope of the audit and will ensure that the audit team is able to focus on the most critical areas. 3. Determine the stakeholders: It is important to identify the stakeholders who will be impacted by the audit. This will help in determining the scope of the audit and will ensure that the audit team is able to address the concerns of all relevant parties. 4. Review the regulatory requirements: The audit team should review the regulatory requirements to ensure that the audit is in compliance with all applicable regulations and guidelines. 5. Develop an audit plan: Based on the objectives of the audit, the areas of focus, and the stakeholders involved, the audit team should develop an audit plan that outlines the scope of the audit and the methodology to be used. II. Assembling the Audit Team

The next step is to assemble an audit team that includes clinical documentation specialists, coding experts, and other relevant stakeholders. The team should have a clear understanding of the audit objectives and the scope of the review. The steps for assembling the audit team are: 1. Identify the necessary stakeholders: The first step is to identify all the stakeholders who should be involved in the audit. These stakeholders may include clinical documentation specialists, coding experts, physicians, nurses, and administrative staff. 2. Determine the roles and responsibilities: Once the stakeholders have been identified, the next step is to determine their specific roles and responsibilities in the audit process. This will ensure that everyone knows what is expected of them and that there is no duplication of effort. 3. Define the reporting structure: The audit team should establish a reporting structure that outlines how information will be shared and how decisions will be made. This will ensure that everyone is on the same page and that there is clear communication throughout the audit process. 4. Ensure adequate resources: The audit team should ensure that they have adequate resources to complete the audit, including access to patient records, coding data, and other relevant documentation. 5. Provide training: If necessary, the audit team should provide training to team members to ensure that they have the necessary knowledge and skills to complete the audit successfully. 6. Establish timelines: The audit team should establish timelines for completing each phase of the audit, including data collection, data analysis, and reporting of findings. This will help ensure that the audit stays on track and is completed in a timely manner. III. Collecting Data The audit team should collect data from various sources, including patient records, coding data, and other relevant documentation. The data should be reviewed and analyzed to identify areas of concern. 1. Identify the type of data you need to collect. 2. Determine the sources from which you can collect the data. 3. Decide on the method of data collection, such as surveys, interviews, or experiments. 4. Design a data collection tool or questionnaire if needed. 5. Pilot-test the data collection tool to identify and fix any issues. 6. Administer the data collection tool for the participants. 7. Organize and store the collected data in a secure and accessible manner.

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8. Analyze the data using appropriate statistical methods. 9. Draw conclusions based on the analysis of the data. IV. Conducting a Preliminary Review Based on the data collected, the team should conduct a preliminary review of the documentation to identify poor documentation and/or inaccurate coding areas. This will help the team focus their efforts on the areas that need the most attention. 1. Define the scope of the review: Determine what aspects of the project, process, or system will be reviewed and identify any specific objectives to be achieved. 2. Assemble the review team: Select a team of individuals with relevant expertise to conduct the review. 3. Collect relevant information: Gather all relevant information, such as project plans, process documentation, and system specifications. 4. Conduct interviews: Conduct interviews with key stakeholders to gain an understanding of their roles and responsibilities, as well as any concerns they may have. 5. Analyze the information: Review the information collected and identify any potential issues or areas of concern. 6. Prepare a preliminary report: Document the findings of the review in a preliminary report, which should include recommendations for further action if necessary. 7. Review and finalize the report: Share the preliminary report with the stakeholders for review and feedback, and make any necessary revisions before finalizing the report. V. Developing an Audit Plan Once the areas of concern have been identified, the audit team can develop an audit plan that outlines the audit objectives, the scope of the review, and the methodology to be used. The plan should also identify the audit team's responsibilities and the timeline for completing the audit. 1. Define the Objective and Scope of the Audit: Begin by determining the objective and scope of the audit. This will help you to identify what you are auditing and what you want to achieve through the audit. 2. Gather Information: Collect all relevant information about the area being audited. This may include policies, procedures, documentation, and other relevant data. 3. Identify Risks: Identify the risks associated with the area being audited. This will help you to determine the areas that require more attention and focus during the audit.

4. Develop the Audit Plan: Based on the information gathered and risks identified, develop a comprehensive audit plan. The plan should include the audit objective, scope, methodology, and resources required to conduct the audit. 5. Review and Approve the Audit Plan: Once the audit plan is developed, review and approve it with the relevant stakeholders. This will ensure that everyone is on the same page and understands the audit objectives and scope. 6. Implement the Audit Plan: Implement the audit plan by conducting fieldwork, testing controls, and gathering evidence to support your findings. 7. Report the Findings: Once the audit is completed, report your findings to management and other stakeholders. Your report should include a summary of your findings, recommendations, and action plans to address any issues identified during the audit. 8. Follow-up: Follow up with management to ensure that the recommended actions are implemented and any issues identified during the audit are addressed. VI. Conducting the Audit During the audit, the team should review the documentation to ensure that it meets the regulatory requirements and that it accurately reflects the patient's condition. The team should also identify any discrepancies or gaps in the documentation, which can then be addressed to improve the overall quality of care provided to patients. 1. Define the scope and objective of the audit. 2. Plan the audit and the resources required. 3. Conduct an entrance meeting with the auditee to explain the audit process and objectives. 4. Gather and analyze information and data relevant to the audit objective. 5. Evaluate the information and data collected against the audit criteria. 6. Document the findings and make recommendations for improvement as necessary. 7. Conduct an exit meeting with the auditee to discuss the findings and recommendations. 8. Prepare the final audit report and distribute to relevant stakeholders. 9. Follow up on the implementation of any recommendations made during the audit. VII. Reporting the Audit Findings After completing the audit, the team should prepare a report that outlines the audit findings, including any areas of concern and recommendations for improvement. The report

should also include a summary of the audit methodology, the scope of the review, and the audit team's responsibilities. Steps for Reporting the Audit Findings Once the audit team has completed its review and analysis of the data, they need to report their findings to the relevant stakeholders. The following steps outline the process for reporting the audit findings: 1. Prepare a summary report: The audit team should prepare a summary report that includes an overview of the audit objectives, the scope of the audit, the methodology used, and the key findings. 2. Share the report with stakeholders: The audit team should share the report with all relevant stakeholders, including clinical documentation specialists, coding experts, physicians, nurses, and administrative staff. 3. Conduct a debriefing session: The audit team should conduct a debriefing session with the stakeholders to discuss the findings and their implications. This session should provide an opportunity for stakeholders to ask questions and provide feedback. 4. Develop an action plan: Based on the findings of the audit, the stakeholders should develop an action plan to address the identified areas of concern. This plan should include specific steps to improve clinical documentation and/or coding accuracy. 5. Monitor progress: The stakeholders should monitor progress towards achieving the action plan goals. This may involve regular meetings, progress reports, and ongoing data collection and analysis. 6. Provide feedback: The stakeholders should provide feedback to the audit team on the effectiveness of the action plan and any improvements that can be made in future audits. Overall, reporting the audit findings is a critical part of the audit process. It provides stakeholders with valuable insights into the strengths and weaknesses of the clinical documentation and coding processes and helps to identify opportunities for improvement. Conclusion In conclusion, preparing for an audit of clinical documentation to address poor documentation and/or inaccurate coding within the CMI requires a clear understanding of the audit objectives and the scope of the review. Assembling an audit team with the necessary expertise and collecting data from various sources is essential. Conducting a preliminary review, developing an audit plan, and conducting the audit are crucial steps in the process. Finally, reporting the audit findings and recommendations is necessary to improve the overall quality of care provided to patients.

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References American Academy of Professional Coders. (n.d.). Importance of Accurate Medical Coding. Retrieved from https://www.aapc.com/resources/research/importance-of-accurate-medical- coding/ American Health Information Management Association. (n.d.). Clinical Documentation Improvement. Retrieved from https://www.ahima.org/Topics/CDI American Health Information Management Association. (n.d.). Documentation Standards. Retrieved from https://library.ahima.org/CDI_EthicalStandards Centers for Medicare & Medicaid Services. (n.d.). Medicare Conditions of Participation (CoPs) for Hospitals. Retrieved from https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/ som107ap_a_hospitals.pdf Centers for Medicare & Medicaid Services. (n.d.). Medicare Learning Network. Retrieved from https://cgsmedicare.com/pdf/bulletins/03-21.pdf