Health & Medical Question

For Module 7 Discussion Topic Paper, please post a 3-page initial response to the following (A title page is not required and please paste your initial discussion directly into your posting). You will be answering all the questions in a 3-page response

3 P + 6 responses

1. Choose one large healthcare organization or system to review and pretend that you will be conducting an independent audit as a consultant. List ten ethical or legal challenges/issues that you may discover when conducting your independent audit for accurate medical coding for either physician practices, hospitals, hospice, or any organization that provides health care services. Explain each challenge/issue/problem that may transpire when conducting your audit.
2. After the audit, you are hired on as part of a consultant team for that healthcare organization or system to develop a best practices medical coding manual for the healthcare organization and/or system, what basic guidelines or rules would you include or recommend for auditing purposes, compliance issues, patient care outcomes, and to better manage clinical operations?

Module 7 Paper
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Pamela Nyagah posted Dec 5, 2023 5:40 PM
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Independent Audit of a Large Healthcare Organization: Ethical and Legal
Challenges in Medical Coding
Conducting an independent audit in a large healthcare organization, particularly
focusing on medical coding for services, unravels numerous ethical and legal
challenges. Medical coding is an intricate process, where patient care information is
translated into standardized codes crucial for billing, insurance claims, and
healthcare statistics. This audit aims to identify and address potential challenges in
this domain.
Identifying Ethical and Legal Challenges:
Inaccurate Coding Practices
Inaccurate coding can lead to significant billing errors, impacting both revenue
generation and patient trust. Errors may arise from a lack of knowledge, oversight,
or in some cases, intentional actions like ‘upcoding’ to secure higher reimbursements.
Such practices not only compromise the integrity of billing processes but also
potentially lead to legal consequences.
Non-Compliance with Coding Guidelines
Healthcare organizations are mandated to follow specific coding guidelines, such as
ICD-10 and CPT. Non-compliance, whether intentional or due to ignorance, can
result in legal repercussions and a decline in patient care quality. This challenge is
often rooted in inadequate training or a lack of awareness about the latest updates in
coding standards.
Confidentiality Breaches
Patient confidentiality is paramount in healthcare. Coding processes, which handle
sensitive health information, are prone to confidentiality breaches. Such breaches,
whether accidental or due to insufficient data security measures, can lead to serious
legal issues and damage the organization’s reputation.
Fraud and Abuse
Deliberate manipulation of coding, known as fraud, is a significant concern.
Identifying such unethical practices is crucial for legal compliance and maintaining
ethical operations. Fraudulent activities might include billing for services not
provided or altering codes to increase reimbursement amounts.
Lack of Adequate Training
Medical coders must be well-versed in current coding standards and practices.
Inadequate training can result in coding errors, negatively affecting billing accuracy
and patient care outcomes. Continuous education and training are essential to keep
the coding staff updated and competent.
Overlapping and Duplicate Coding
Overlapping or duplicate coding can lead to redundant procedures or medication
errors, which compromise patient safety. This issue often arises from disorganized
record-keeping or communication lapses between different departments or
healthcare professionals.
Upcoding and Undercoding
Upcoding (coding for higher-level services) and undercoding (coding for lower-level
services) to influence insurance reimbursements are both unethical and illegal. These
practices can lead to insurance fraud charges and compromise the integrity of patient
care.
Inadequate Documentation
Incomplete or inaccurate patient records can lead to incorrect coding, impacting
billing accuracy and patient care. Ensuring complete and precise documentation is a
prerequisite for accurate medical coding.
Coding for Non-Covered Services
Coding services that are not covered by insurance plans as if they were, is unethical
and can lead to legal issues. This practice misleads patients and insurance providers,
undermining the trust in the healthcare system.
Cultural and Language Barriers
Misinterpretations due to cultural and linguistic differences can result in incorrect
coding, especially in a diverse patient population. This challenge necessitates
cultural competence and sensitivity in the coding process.
Developing a Best Practices Medical Coding Manual:
Upon completing the audit, as part of a consultant team, the development of a best
practices manual for medical coding is essential. This manual should encompass
guidelines that address the identified challenges, promoting ethical, legal, and
efficient coding practices.
Comprehensive Training Program
Implement a robust training program to keep the coding staff updated with the latest
coding standards and healthcare regulations. Regular training sessions will ensure
proficiency and adaptability in the ever-evolving field of medical coding.
Adherence to Coding Guidelines
Emphasize strict adherence to standard coding systems like ICD-10 and CPT.
Understanding and following these guidelines accurately is crucial for maintaining
legal compliance and high-quality patient care.
Robust Confidentiality Policies
Develop stringent measures to maintain patient confidentiality during the coding and
billing processes. This includes secure handling of patient data and implementing
strong data security protocols.
Regular Audits and Compliance Checks
Establish a system for regular internal audits to identify and rectify coding
inaccuracies and non-compliance issues. These checks will ensure ongoing
adherence to ethical and legal standards.
Fraud Prevention Measures
Incorporate clear policies to detect and prevent coding fraud and abuse. Establishing
reporting mechanisms for unethical practices will foster a culture of integrity and
accountability.
Error Reporting and Correction Procedures
Develop a transparent system for reporting coding errors and a structured process for
their correction. This will enhance the accuracy of coding and billing processes.
Clear Documentation Guidelines
Set stringent guidelines for clinical documentation, ensuring completeness and
accuracy to support appropriate coding. This will mitigate issues arising from
inadequate documentation.
Cultural Competence Training
Include training modules that address cultural and linguistic competencies. This will
minimize errors due to misinterpretation in a diverse patient population.
Ethical Coding Practices
Reinforce the importance of ethical coding. Highlight the legal and moral
implications of practices like upcoding, undercoding, and coding for non-covered
services.
Technology Utilization
Recommend the adoption of advanced coding software and tools. Utilizing
technology will enhance the accuracy and efficiency of the coding process.
By addressing these key areas, the medical coding manual can serve as a
comprehensive resource, guiding the healthcare organization through the
complexities of medical coding. It will not only improve coding accuracy and
compliance but also enhance patient care outcomes and the overall efficiency of
clinical operations.
Module 7 Paper
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Tara Sepe posted Dec 4, 2023 3:33 PM
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Auditing in Healthcare
Auditing is essential to keeping an organization on track to follow
guidelines, ensure safety, and build a framework to assess the coding and billing
aspects. The healthcare organization I will be choosing to audit is Southern Illinois
Healthcare (SIH). There is an abundance of issues that may come up while
conducting my independent audit of this organization.
The first issue that may come to light is inaccurate documentation.
Documentation is crucial for the billing and reimbursement processes. If inaccurate
documentation is present, it can result in many issues, such as wrong treatment
options, wrong medication, and wrong surgical errors. If inaccurate documentation
is abundant, it can result in charges against the organization including malpractice
and negligence.
The next issue I may find while auditing Southern Illinois Healthcare is
non-compliance with regulations. This can lead to hefty fines against the
organization. If there are an abundance of fines, they can add up quickly and put
the healthcare organization in debt. It can also potentially damage the
organization’s reputation and even lose patient trust.
Patient privacy and confidentiality are two of the biggest issues occurring in
healthcare today. Organizations must do a better job of ensuring all patient
information is sacred. If patient information is found to be at risk during my audit,
it can lead to legal violations, damage the organization’s reputation, and lose patient
trust if not addressed immediately.
The fourth issue that may arise during an independent audit of Southern
Illinois Healthcare is the training of employees. Staff must be adequately trained
and prepared for any issue that comes up during their time working. They must
know how to document correctly to ensure coders can code correctly. Staff also
must know how to do their basic job duties to ensure that everything runs smoothly
and that everyone remains safe. Inadequate training can result in coding errors and
compliance issues.
Effective communication is key when it comes to organizations being
successful. All areas of the organization must ensure that they have adequate
communication with each other. If there is a lack of communication within the
organization, this can lead to coding discrepancies and impact the overall accuracy
of the coding process. It can also lead to detrimental medical errors.
Timeliness of documentation is another issue that can come up while
auditing a healthcare organization. Codes must be assigned promptly to ensure the
process runs smoothly. If there were to be any delays in the documentation process,
it may lead to errors while coding as well as impact the quality of care given to a
patient. It can also delay the billing and reimbursement process, which can lead to
many issues for the organization.
The seventh issue that may potentially come up during the auditing process
is either upcoding or downcoding. Upcoding is when there is a code assigned that
is higher than justified. Downcoding is assigning a lower-level code to minimize
reimbursement. These issues could lead to overbilling or underbilling. It could
cause financial issues and affect the quality of care for a patient.
Fraud and abuse are another huge issue when it comes to healthcare
organizations. Fraud and abuse can include billing for services or supplies that
were not provided, falsifying records or claims, and poor care coordination. This
can lead to legal issues, including fines and penalties under healthcare fraud laws.
The ninth issue that may arise while conducting my audit is not verifying
insurance. Not verifying insurance can lead to an unpaid claim by the patient’s
insurance company. It also prevents the patient from paying their bill on time.
The last issue that I could find while conducting an independent audit was
documenting the incorrect patient’s name. They could be given the wrong
treatment plans, the wrong medications, or even the wrong surgeries or transplants.
Patients could lose their lives from this, so physicians must double-check their
work to ensure their documents include the correct patient.
After the audit of Southern Illinois Healthcare, I have come up with rules
and guidelines to include or recommend for auditing purposes, compliance issues,
patient care outcomes, and to better manage clinical operations. For auditing
purposes, the organization must conduct regular audits to ensure compliance with
coding guidelines. Peer review must also occur to review and validate coding
decisions. For coding guidelines, there must be regular training programs put into
place to keep staff up to date on changes within healthcare, the organization, and
coding guidelines and regulations. The organization could also hire a compliance
officer to motivate employees to follow guidelines. They oversee coding practices
and ensure everyone is complying with rules and regulations. For patient care
outcomes, I will strongly encourage communication between providers. It makes
everyone aware of things going on within the organization, and it improves the
accuracy of documentation. Lastly, for clinical operations management, I will
emphasize the importance of continuous process improvement. Implementing a
culture of process improvement can encourage all staff to provide suggestions on
what they think would better our organization. Emphasizing the importance of
adhering to compliance guidelines, ethical behavior, transparency, and integrity in
coding and documentation practices is crucial for employees. It helps them to do
better as well as make the organization better. Overall, coding is an incredibly
important process in healthcare to ensure safety in all aspects. Finding
discrepancies and knowing the consequences is crucial for managers to be aware
of.
References
Compliancy Group. (2023, September 18). The Cost of Non-Compliance in
Healthcare: A Deep Dive into the Consequences. https://compliancygroup.com/the-cost-of-non-compliance-inhealthcare/#:~:text=The%20cost%20of%20non%2Dcompliance%20in%20h
ealthcare%20can%20be%20staggering,reputation%20and%20losing%20pat
ient%20trust.
Zellers, A. (2023, May 30). How to handle a healthcare audit. ChartRequest.

How to Handle a Healthcare Audit

Module 7 Paper
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Jill Heflin posted Dec 6, 2023 7:16 AM
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1. Choose one large healthcare organization or system to
review and pretend that you will be conducting an
independent audit as a consultant. List ten ethical or legal
challenges/issues that you may discover when conducting
your independent audit for accurate medical coding for
either physician practices, hospitals, hospice, or any
organization that provides health care services. Explain
each challenge/issue/problem that may transpire when
conducting your audit.
2. After the audit, you are hired on as part of a consultant
team for that healthcare organization or system to
develop a best practices medical coding manual for the
healthcare organization and/or system, what basic
guidelines or rules would you include or recommend for
auditing purposes, compliance issues, patient care
outcomes, and to better manage clinical operations?
Audits are extremely important to a healthcare organization as
they show what a facility is doing right and what they can
improve on. Utilizing this tool helps to ensure that the
healthcare organization is following regulatory guidelines and
policies and procedures. Furthermore, medical coding audits
can assist in detecting issues with incorrect documentation and
improper billing. Performing regular and ongoing auditing can
improve clinical documentation and coding initiatives, increase
communication within the organization, and enhance data
integrity (Wilde, 2019). I will be conducting an independent
audit of Rush University Medical Center’s Medical Coding and
Billing Department. The goal of this audit is to eliminate coding
errors and to minimize claim denials.
The first issue that I may come across is outdated coding. It is
imperative that the medical coder use the most recent version
of ICD codes and CPT codes so that the facility will receive full
reimbursement. Also, the medical codes must comply with the
payer’s policies. The second issue that may arise is lack of
documentation. The medical codes are dependent on the
documentation that is provided in the patient’s chart. If key
elements of the patient’s care are missing from the
documentation, then the medical coder will not be able to code
to the fullest extent.
While reviewing charts for laboratory charges and billing, there
may be problems with the bundling of lab tests. The third issue
that may transpire is several laboratory tests were billed
separately when a bundled code should have been used. Then
in the fourth example, a bundled laboratory test was billed, but
not all tests were completed in the bundle set. If unbundling
occurs, this can be seen as intentional up-coding.
The next issue that could transpire during this audit is double
billing. An example of this would be if the hospital billed
Medicare/Medicaid and a private insurance company for the
same procedure or treatment. This type of situation puts the
organization at risk of being fined, and revenue would be lost as
this would cause delays in the reimbursement process. A sixth
issue that may come to light is upcoding. Upcoding occurs
when a provider seeks reimbursement using a fraudulent CPT
code that provides a higher reimbursement than the correct
CPT code that corresponds to the services that were provided.
Upcoding is considered a form of fraud and puts the
organization at significant risk for legal consequences, including
fines and penalties.
Another issue that I may see during my audit is failure to meet
medical necessity. Medical necessity is services or items
reasonable and necessary for the diagnosis or treatment of
illness or injury. Claims that do not meet medical necessity will
be denied and this adds extra burden on the organization. The
ICD -10 codes should support the medical necessity for
services that are billed.
Failure to comply with standards and regulations is another key
issue that may transpire within this healthcare organization.
These regulations are necessary to reduce billing mistakes and
guarantee uniform billing methods across the sector. By
following standards and regulations, healthcare professionals
can support correct reimbursement, avoid billing disputes, and
contribute to the financial stability of healthcare organizations.
The ninth issue that may arise during my audit concerns patient
privacy and confidentiality. Medical billing and coding
specialists will see sensitive information in patient’s records,
and it is imperative that this remains confidential at all times.
Employees should not be accessing medical information that is
not relevant to the treatment, service, or procedure that they
are handling in billing and coding.
Lastly, inadequate training of staff can have negative
consequences for the healthcare organization. Proper training
of medical coders can help to eliminate billing errors and
increase revenue. It is vital for the staff to be up to date on the
latest compliance regulations, best practice standards, and
medical coding updates.
I recommend that Rush University Medical Center conduct
internal audits on a quarterly basis. These audits have a positive
impact on the organization by increasing performance
improvement and compliance. Furthermore, audits can help to
ensure that outdated codes are not being used or incorrect
billing practices have been corrected. Also, all medical coding
and billing staff should be required to attend training sessions,
workshops, and seminars. The main focus of these training
sessions should be regulatory compliance, HIPPA, and open
communication. Also, clear documentation practices need to
be established in all departments. By applying consistent
documentation processes across all departments improves
reliability. I believe that my recommendations can increase
efficiency and accuracy in this Coding and Billing Department.
Reference:
Wilde, Cathie (2019). MRA. Back to the Basics: How to do an
Internal Coding Audit. Retrieved from Back to the Basics: How
to Do an Internal Coding Audit – MRA | #1 Provider of Coding
Auditing Cancer Registry Services (mrahis.com)
DB 7 Paper2
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Katie Corcoran posted Dec 5, 2023 8:56 PM
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Healthcare Audits
The healthcare organization that I am choosing is OSF
Healthcare. The first piece of information that is important to
understand is what an audit is and the purpose of conducting
an audit. An audit is an inspection of an individual or an
organization’s accounts. An independent organization usually
does this. Auditing helps healthcare organizations maintain
accurate and appropriate documentation, optimize revenue,
minimize compliance risks, and improve operational efficiency.
Above all, it’s an essential step in creating accountability.
(Jones, 2023) Now that we have established the point of a
healthcare audit, I have decided to do an independent audit of
the OSF healthcare system.
One of the first issues I found that could be flagged is patient
privacy and confidentiality. The information discussed between
that patient and the doctor must remain confidential.
Healthcare organizations must ensure that they are protecting
the patient’s information and that it is secure. If, when
conducting an audit, a patient’s information is found floating
around, that could lead to legal issues because there is a risk of
HIPPA violations from the patient’s information not being in a
secure location.
The second issue I may find when conducting my audit is the
transmission of diseases. This is an essential thing to be aware
of because if the proper steps are not taken when dealing with
patients who may have a communicable disease, this can
happen when the patient’s health history is not adequately
shared with the staff in direct contact with this patient. Ethical
and legal questions arise when a patient’s health history is not
provided to the medical staff. (Lsanchez, 2022)
Third could be any end-of-life issues. Some patients could have
specific wishes and medical directives on how they want things
down regarding the end of life. This can sometimes be difficult
for family members. to navigate, so having these directives in
place can help ease the struggle of making these decisions.
Medical personnel must follow these directives because if they
stray from them, it can lead to legal issues if the patient’s
wishes are not followed. In some cases, though, medical
professionals may not feel ethically comfortable upholding this
medical directive and the rights of patients. (Lsanchez, 2022)
Fourth could be the relationship between the patient and the
medical professional. This would fall under the healthcare
facility’s code of ethics and conduct. If an inappropriate
relationship occurs between the patient and the medical
practitioner, this would be considered unethical. This also goes
for the medical staff; relationships between colleagues can
quickly become problematic. Inappropriate relationships
between management and staff are rife with potential for
abuse, coercion, and sexual harassment. (Lsanchez, 2022) While
conducting my audit, the healthcare organization could face
fines for violating the code of ethics if there are signs that this
is happening.
The fifth issue that could happen is incorrect documentation; if
there is erroneous documentation, this can lead to several
problems. When documenting, the reported information must
be correct and accurate because if things are incorrectly
entered, this can affect the billing process. When this happens,
it could lead to charges such as fraud, malpractice, or
negligence. These will affect the healthcare organization as well
as their reputation.
Another thing that could be considered during my independent
audit is how the facility manages conflicts of interest. This is
important because the area where OSF is located is rural, and
many people know each other, so knowing how the
organization handles these conflicts is crucial because it is
unethical to provide care to someone you have a personal
relationship with.
The seventh thing that can be examined during an audit is the
Informed Consent forms patients should sign when they come
for an appointment or procedure. Informed Consent is a form
that a patient would sign before medical treatment. This shows
the patient has the right to receive information and ask
questions about the treatment options so that they can make
informed decisions regarding their care. Patients who have not
signed one of these forms may not consent to the medical
treatments. There is an exception in emergencies where the
patient cannot make decisions. That is the only time a physician
can initiate therapy without the patient’s Consent.
Another area that can be investigated during an audit is the
DNR forms. A DNR is a form signed by the patient stating they
do not wish to be resuscitated or any life-saving measures. If a
patient has a cardiac episode that is causing that patient to
flatline or “code” if they have a DNR signed, no life-saving
measures should be taken. If a patient is resuscitated and has a
DNR and the medical staff were not aware of this, it could lead
to legal action from the patient or the patient family for going
against the patient’s wishes.
The ninth issue that could be found during the independent
audit is withholding or withdrawing life-sustaining treatments.
“Decisions to withhold or withdraw life-sustaining interventions
can be ethically and emotionally challenging to all involved.
However, a patient who has decision-making capacity
appropriate to the decision at hand has the right to decline any
medical intervention or ask that an intervention be stopped,
even when that decision is expected to lead to their death and
regardless of whether the individual is terminally ill.” (AMA,
2023).
Physician Self-referral is the last item that could be looked at
during an independent audit. A physician self-referral is when a
doctor within the healthcare marketplace can benefit from
referring patients to other doctors outside of the practice for
financial gain. “Physicians should not refer patients to a health
care facility outside their office practice and at which they do
not directly provide care or services when they have a financial
interest in that facility.” (AMA, 2023). This is unethical because
the physician is then getting a kickback from referring that
patient to that healthcare office because they have a financial
interest within that office.
After completing my audit at OSF Healthcare, I would ensure
that regular audits are done within the facilities to ensure that
they run smoothly and efficiently and provide the best care
possible. I also established that more attention needs to be
given to ensuring that more patient safeguards are in place to
ensure patient information is safe and secure. Another way to
ensure that the healthcare facility is up to standards is by
regularly updating our policies to serve the community to the
best of our abilities.
Reference:
Jones, S. (2023, November 22). What is medical
auditing? MedTrainer. https://medtrainer.com/blog/medicalauditing/#:~:text=Auditing%20helps%20healthcare%20organiz
ations%20maintain,important%20step%20in%20creating%20ac
countability.
Lsanchez. (2022, September 27). Ethical issues in Healthcare.
uttyler. https://online.uttyler.edu/degrees/business/mba/healt
hcare-management/ethical-issues-in-healthcare/
Withholding or withdrawing life-sustaining treatment. AMA.
(2023). https://code-medical-ethics.ama-assn.org/ethicsopinions/withholding-or-withdrawing-life-sustaining-treatment
MODULE 7 – PAPER
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Jessi Marin Guarin posted Dec 5, 2023 2:17 PM
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In the context of our independent healthcare audit, precise medical
coding emerges as crucial for compliance, patient care, and
streamlined operations in a distinguished healthcare organization
dedicated to excellence. The chosen entity grapples with inherent
challenges related to accurate medical coding.
•
Upcoming and Unbundling: Significant hurdles arise from upcoding, where higher-level codes are assigned for financial
gain, raising ethical concerns. Simultaneously, unbundling
procedures meant to be together posed financial and ethical
dilemmas.
•
Insufficient Documentation: Pervasive challenges in
documentation impact code accuracy and patient care.
Incomplete records not only affect finances but jeopardize the
quality of care provided.
•
Fraudulent Billing Practices: Instances of fraudulent billing,
exaggerating patient conditions or billing for services not
rendered, are uncovered during audits, posing financial,
ethical, and legal concerns.
•
Non-Compliance with Regulations:Adherence to evolving
coding guidelines and regulations, including CMS updates,
proves a constant challenge, risking legal consequences and
demanding an agile response to changes.
•
Incomplete Staff Training: The absence of comprehensive
training in coding and documentation challenges staff
proficiency, emphasizing the need for ongoing education to
ensure accuracy and compliance.
•
Insufficient Internal Auditing Processes: Internal audit
challenges highlight the need for a robust system to identify
issues promptly, ensuring ongoing compliance with coding
standards and regulations.
•
Coding for Medically Unnecessary Services: Coding without
medical necessity poses legal and ethical challenges,
emphasizing the importance of aligning codes with a patient’s
clinical condition.
•
Conflict of Interest: Uncovering conflicts of interest influencing
coding decisions underscores the need for transparent and
unbiased coding practices to maintain integrity.
•
Underreporting of Adverse Events: Ethical concerns arise with
underreporting adverse events to avoid legal repercussions,
emphasizing transparent reporting practices for patient safety.
•
Patient Privacy Concerns: Ensuring coding practices align with
patient privacy laws is paramount to prevent legal and ethical
dilemmas and maintain patient trust.
Post-audit, a comprehensive medical coding manual becomes
essential, guiding the healthcare organization/system through the
complexities of coding.
•
Continuous Staff Training: Ongoing training ensures a
proficient coding workforce updated on guidelines,
regulations, and industry best practices.
•
Documentation Integrity: Emphasize thorough documentation
to support accurate code assignment, encouraging clear and
comprehensive records from clinicians.
•
Regular Internal Audits: Establish routine internal audits to
promptly identify and rectify coding errors, contributing to
ongoing accuracy and compliance.
•
Transparency in Reporting: Encourage transparent reporting
practices for adverse events, fostering a culture of continuous
improvement, legal compliance, and ethical standards.
•
Compliance Monitoring: Implement systems for monitoring
coding guideline compliance, regularly reviewing practices to
align with evolving regulatory requirements.
•
Patient Privacy Safeguards: Ensure robust measures for patient
privacy, incorporating safeguards into coding protocols to
protect patient data.
•
Code Review and Validation: Establish a process for regular
code review and validation to minimize errors, ensuring codes
reflect the latest and most relevant information.
•
Interdisciplinary Collaboration: Promote collaboration between
coding professionals and clinicians for comprehensive coding,
fostering cohesion between departments.
•
Patient-Centric Approach: Encourage coding practices aligned
with a patient’s clinical condition and care outcomes,
contributing to a holistic understanding of patient health.
•
Regular Policy Updates: Keep coding policies updated in line
with industry standards and regulations, communicating
changes proactively to ensure an informed approach to
compliance.
In conclusion, the highlighted challenges and guidelines underscore
the intricate balance required for ethical, legally compliant, and
operationally efficient medical coding. A commitment to addressing
challenges and implementing best practices will fortify the
organization’s ethical standing and enhance overall healthcare
service quality. The proposed guidelines serve as a roadmap for
navigating the dynamic landscape of medical coding, ensuring
continual improvement and compliance.
DB #7 Paper
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Elizabeth Krueger posted Dec 4, 2023 2:27 PM
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Module #7 Paper
Choose one large healthcare organization or system to review and
pretend that you will be conducting an independent audit as a consultant.
List 10 ethical or legal challenges/issues that you may discover when
conducting your independent audit for accurate medical coding for either
physician practices, hospitals, hospice, or any organization that provides
health care services.
Explain each challenge/issue/problem that may transpire when
conducting your audit.
After the audit, you are hired on as part of a consultant team for that
healthcare organization or system to develop a best practice medical coding
manual for the healthcare organization and/or system, what basic guidelines
or rules would you include or recommend for auditing purposes, compliance
issues, patient care outcomes, and to better manage clinical operations?
Electronic Health Records (EHRs) provide the opportunity to enforce the
better practices for auditing purposes, compliance issues, patient care outcomes, and
to better manage clinical operations. Efforts are under way to improve the quality of
alcohol-related primary care, including implementing preventive screening and brief
intervention as well as engaging patients in care for alcohol use disorders (1975). As
these efforts proceed, health systems need practical, valid approaches to measuring
changes in patients’ drinking over time in response to interventions (1976).
One approach to monitoring responses to alcohol-related primary care
interventions would be to use scaled scores from alcohol screening, similar to the
current use of depression screens. One commonly used screen that might be useful
for monitoring is the 3-item Alcohol Use Disorders Identification Test-Consumption
(AUDIT-C) questionnaire. As AUDIT-C scores increase, average alcohol
consumption increases from 0 to 18 drinks a day, and the risk of DSM-IV alcohol
dependence increase from 0 to 65%. However, despite demonstration of the criterion,
discriminative, and predictive validity of the AUDIT-C in research settings, AUDITC scores may have lower validity when documented in EHRs as part of routine
clinical practice (‘clinical screening’) (1976).
The predictive validity of clinical AUDIT-C screening can be estimated
through three objective alcohol-related outcome measures, using secondary data
from the US Veterans Affairs (VA) health system, which provides medical care for
eligible military veterans. The first aim is to estimate the association between scores
on a single clinical AUDIT-C and each outcome measure in the following year. The
second aim is to assess the association between changes in AUDIT-C risk group,
from baseline to annual re-screening, and the same three outcomes in the year after
re-screening (1976).
The AUDIT-C asks about past alcohol use. Therefore, two screens ≥ 12
months apart could reflect reported drinking during consecutive, non-overlapping
time-periods. AUDIT-C scores can be used in two ways. For Aim 1 analysis of the
predictive validity of a single clinical AUDIT-C, continuous AUDIT-C scores (0-12)
would be used. For descriptive purposes, Aim 2 analyses, both baseline and follow
up AUDIT-C scores categorized into five AUDIT-C groups. These AUDIT-C risk
groups can be used for Aim 2 analyses of changes in AUDIT-C, instead of continuous
AUDIT-C scores, because use of all 13 possible AUDIT-C scores (0-12) would result
in 169 different possible combinations of baseline and follow-up scores, making
results imprecise and difficult to interpret. AUDIT-C risk groups can be selected
based on prior research demonstrating: poorer outcomes in patients with no alcohol
use compared to low level use; validated screening thresholds for mild alcohol
misuse; and AUDIT-C thresholds for health risks (1977).
Outcome measures would include: one alcohol biomarker- a continuous
measure of high-density lipoprotein cholesterol (HDL) in milligrams per deciliter
(mg/dl), and two binary health outcomes- hospitalization for gastrointestinal
conditions associated with alcohol misuse (‘GI hospitalizations’) and physical
trauma. Each outcome measure is chosen because it is associated with alcohol
consumption and AUDIT-C scores obtained from confidential surveys, often in a
‘dose-response’ manner. However, the association between clinical alcohol
screening documented in EHRs and these outcomes has not been reported previously.
HDL, a biomarker of recent average alcohol consumption, is typically ordered to
assess cardiovascular risk in patients with or without other cardiovascular risk
factors, and 61% of the study sample could have HDL measured in the year after
both baseline and follow-up AUDIT-Cs (1977).
Covariates, selected prior based on their availability from VA databases and
known or potential associations with alcohol misuse and all three outcomes, include
gender, age, race, marital status and VA facility at baseline, VA eligibility at baseline
and follow-up and days between baseline and follow-up AUDIT-C. VA facility is
included because the quality of screening, as well as alcohol misuse and outcomes,
may vary by facility. These same covariates can be used in models for all three
outcomes, so that differences in findings will not attribute to differences in
covariates (1977).
Demonstrating the predictive validity of alcohol screening would be
documented in the EHR as part of routine clinical care for one alcohol biomarker
(HDL) and two objective alcohol-related outcomes: GI hospitalizations and physical
trauma. Baseline AUDIT-C score has a positive, dose-response association with all
three outcomes in the following year. These results are an important complement to
prior studies that evaluate the discriminative and predictive validity of AUDIT -Cs
when results are not documented in patients’ medical records. In addition, there are
few studies on the assessment of the predictive validity of changes in clinical alcohol
screening scores documented in EHRs. For patients who increase to moderate or
severe alcohol misuse at follow-up, from lower baseline AUDIT-C scores, result in
consistency across the three outcomes: meaning HDL and the probabilities of GI
hospitalizations and trauma in the year after follow-up screening are consistently
higher in those who increased to AUDIT-C scores compared to stable
patients (1979).
However, findings are not consistent across the three outcomes for patients
who decrease their AUDIT-C scores at follow-up. Changing to a lower AUDIT-C
group at follow-up is associated with lower HDL and –among patients with severe
alcohol misuse at baseline- lower risk of GI hospitalizations. However, lower risks
of GI hospitalizations are not observed for the remainder of patients who change to
a lower AUDIT-C group at follow-up, and there are no changes to the lower AUDITC group are associated with lower risk of trauma (1980).
Under-reporting on clinical AUDIT-Cs might undermine the predictive
validity of clinical AUDIT-Cs, biasing findings towards the null. Therefore, it is
assumed there is no association with outcomes in the year after the AUDIT-C, in
contrast to prior studies using AUDIT-Cs from mailed surveys. However, it has been
observed there are strong positive associations between clinical AUDIT-C scores and
all three outcomes. This probably reflects the fact that while many patients with high
levels of alcohol consumption under-report their drinking in clinical settings, the
majority of patients who report drinking at lower levels are not under-reporting.
Therefore, the few ‘under-reporters’ are offset by the larger sample of accurate
‘reporters’ at lower levels (1981).
The findings of studying the predictive validity of clinical AUDIT-C alcohol
screening in a Veterans Affairs population may have important implications for
quality improvement or clinical leaders interested in monitoring outcomes in
populations of primary care patients after preventive alcohol screening and brief
intervention, and those who do not may benefit from additional brief interventions.
Findings suggest that annual rescreening with the AUDIT-C may be useful for
monitoring to identify high risk populations and assess which patients have
decreased risk at follow up (1981).
Additionally, these findings may also have implications for researchers
conducting pragmatic trials or comparative effectiveness research on different
approaches to implementation of brief interventions. Investigators conducting such
studies need a valid, population-based outcome measure available routinely from
EHRs. The majority of patients who screen positive on alcohol screening
questionnaires have mild misuse, and the purpose of brief interventions is to reduce
drinking and ultimately prevent adverse alcohol-related health outcomes in these
patients (1981).
Studies of strategies for implementing brief interventions as part of routine
care for patients without alcohol use disorders should therefore consider using the
proportion of patients who increase from moderate to severe alcohol misuse at
follow-up as a more clinically meaningful main study outcome than decreases in
consumption. Such an outcomes would be consistent with the preventive focus of
brief interventions (1981).
There is a possibility of several limitations and ethical or legal
challenges/issues that you may discover when conducting an independent audit for
accurate medical coding in AUDIT-C scores and including alcohol screening
documented in the EHR as part of routine clinical care for one alcohol biomarker
(HDL) and two objective alcohol-related outcomes: GI hospitalizations and physical
trauma. First, it is restricted to VA out-patients in one of four regions and, for HDL
analyses, who have had cholesterol tests, potentially biasing results (1982).
Patients also who do not visit the VA annually would be missed, as would GI
hospitalizations and trauma care not provided by VA or covered by Medicare. The
sample would also likely be predominantly male, with a mean age of 68. Younger
patients also drink more on average at high AUDIT-C scores and may be more likely
to receive trauma care not captured by VA or Medicare. Both women and younger
patients may also have differing alcohol-related risks and may be more susceptible
to social desirability bias. Given known limitations in the quality of AUDIT -C
screening in the VA, the predictive validity changes in clinical AUDIT-Cs might be
greater in health systems that collect AUDIT-C data directly from patients in a
standardized manner (1982).
Source
Bradley, K, A., Rubinsky, A. D., Lapham, G. T., Berger, D., Bryson, C.,
Achtmeyer, C., Hawkins, E. J., Chavez, L. J., Williams, E. C., &
Kivlahan, D. R. (2016). Predictive validity of clinical Audit-C
alcohol screening scores and changes in scores for three objective
alcohol-related outcomes in a Veterans Affairs population.
Addiction, 111(11), 1975-1984.