Scenario: You are the manager of the coding department for a healthcare organization and have found a coding error while doing a preliminary compliance audit of claims submission to Medicare. You found that the physician has entered incorrect procedure codes on encounter forms and found similar errors on other supporting documentation, such as patient visit summaries, electronic medical records, etc., for the last quarter. You also notice that the documentation and coding policies and procedures have not been updated in three years. You need to examine the situation and recommend actions to mitigate the error.
Directions: Create a situation, background, assessment, recommendation (SBAR) analysis using the template provided in uploaded files to assess the documentation and coding scenario and recommend ways to rectify the situation. Explain the situation in detail, followed by background information. Include any assumptions you are making about the situation. Then explain the immediate assessment and recommendations you have for your supervisor. All the claims in your deliverable should be evidence based. Your citations should be from your independent search for evidence of credible sources and be current within the last five years. Specifically, you must address the following rubric criteria:
1. Situation: Analyze the situation for elements of concern relating to compliance and financial reimbursement. Consider the following questions to guide your response:
– What is the problem, and how or where did it begin?
– How severe is the problem as it relates to organizational risk and financial performance?
2. Background: Explain the essential information related to the compliance and reimbursement situation. Consider the following questions to guide your response:
– What is the current status of the situation?
– Who should receive communication about the problem?
3. Assessment: Assess the concerns adequately based on the situation and the background information. Consider the following questions to guide your response:
– What is your understanding of the situation, and why must it be addressed immediately?
– What are your assumptions about the root cause of the problem?
4. Recommendation: Recommend at least two ways to resolve the problem based on the situation, background, and your assessment. Consider the following questions to guide your response:
– How would you educate the physician and other providers using evidence-based research and guidelines?
– How would you deliver your recommendation in various learning environments?
All the claims in your deliverable should be evidence based. Your citations should be from your independent search for evidence of credible sources and be current within the last five years.