HIM 600 Module 3 Final Project Milestone One Example

Final Project Milestone One: What the Records Show. A Patient Record Analysis of Office Visits and Injection Claims at Sawtooth Bone and Joint

[Student Name]

Southern New Hampshire University

HIM 600: Managing Compliance

Final Project Milestone One

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Final Project Milestone One: What the Records Show. A Patient Record Analysis of Office Visits and Injection Claims at Sawtooth Bone and Joint

Sawtooth Bone and Joint, a composite orthopedic and spine group of 38 physicians in Boise, Idaho, has never audited its own coding. Two patterns in its billing data prompted this review. Return visits coded 99215 now form about twice the share they did since the 2021 office visit guideline changes, and almost every visit that includes a joint injection is billed with a separate office visit and modifier 25. This milestone analyzes a sample of records to learn whether documentation supports the codes billed, where it falls short and why. Its findings set the baseline for the coding compliance program proposed in the final project.

Scope and Sample

The review covered claims with dates of service from April through June 2026. Two strata were drawn at random from the practice management system: 40 established patient visits billed as 99215 across 22 physicians and advanced practice providers, and 20 visits in which a large joint injection was billed together with an office visit carrying modifier 25. All 60 records were reviewed in full, including the visit note, orders, procedure note and any time statement. The sample is a probe, meant to show whether a problem exists and how large it might be, rather than a statistically valid sample for estimating an overpayment across all claims. That larger step, if needed, belongs to the auditing plan.

Review Method

Each office visit was scored against the current guidelines, which set the level by medical decision making or by total practitioner time on the date of the encounter. For decision making, the reviewer judged the number and complexity of problems, the data reviewed and the risk of patient management, and two of the three had to reach the high level to support 99215. For time-based claims, the note had to state the total time and what it covered. For modifier 25, the question was whether the note described a significant, separately identifiable evaluation beyond the usual pre-procedure assessment that is already part of the injection. Diagnosis codes were checked for specificity, including laterality. A second certified coder independently reviewed ten records, and the two reviewers agreed on nine.

Findings: Top-Level Office Visits

Of the 40 visits billed as 99215, 22 (55%) were supported. Fourteen (35%) supported 99214 and four (10%) supported 99213, so 18 of 40, or 45%, were billed above what the documentation shows. Table 1 summarizes the results by stratum.

The most frequent reason was risk. Thirteen notes counted a discussion of possible surgery as high risk without documenting the patient factors that make an elective major operation risky, such as severe diabetes or anticoagulation, so the decision supported a moderate rather than a high level. Six notes claimed level five on time but recorded no total time, only a phrase such as extended counseling. In four records the physician's assessment simply restated the patient's history from the prior visit without any new analysis, which left the problem count at a lower level than billed.

Table 1. Record Review Results by Stratum, April to June 2026

Note. Supported means the documentation met the guideline requirements for the code and modifier billed.

Findings: Modifier 25 on Injection Visits

Of the 20 injection visits, nine (45%) documented a separate problem or a substantial new evaluation, such as a patient returning for a knee injection who also reported new shoulder pain that was examined and treated. The other 11 (55%) described only the decision to repeat an injection for a known condition, which is part of the injection itself. Several of these notes used a template that automatically generated a full examination, so the visit looked larger on screen than the work actually done. Because injections carry a global period of zero days, the brief evaluation leading to the procedure is already paid within it.

Findings: Documentation Quality

Three further problems appeared across the sample. Seventeen of the 60 notes (28%) contained an examination paragraph identical, word for word, to the same patient's previous note, including findings such as an effusion that the assessment said had resolved. Tsou et al. (2017) found copying to be a near-universal habit among clinicians, one that carries old mistakes into new notes and leaves a record arguing with itself, exactly the pattern in these charts. Five injection claims used a diagnosis code without laterality even though the procedure note named the side. Finally, two notes signed by advanced practice providers were billed under a physician's number without documentation that the physician was present for the visit.

Root Causes

Interviews with six physicians, the billing manager and two coders point to four causes. First, the practice never trained clinicians on the 2021 guidelines beyond a vendor webinar, and the electronic record suggests a level from a template rather than from the decision documented. Balusu et al. (2026) found that orthopedic providers' confidence in their own coding did not predict their accuracy and that education on the new guidelines improved accuracy, which matches what physicians here described: they felt certain of levels that the notes did not support. Second, no one gives feedback; coders release claims as the physician selects them. Burks et al. (2022), reviewing outpatient billing studies, named weak education, documentation that does not support the level billed and the absence of a feedback system as the main reasons for inaccurate billing, and all three are present at Sawtooth. Third, injection templates generate a full examination by default. Fourth, the billing system has no edit that questions a modifier 25 attached to a repeat injection for the same diagnosis.

Implications for the Compliance Program

The error rates are high enough to require action now. Any overpayments identified in these 29 claims should be calculated and refunded, and the practice should decide with counsel whether a larger statistically valid review is needed to estimate exposure across the full period since 2021. The findings also define the program's first priorities: education on decision making and time documentation, a rule for modifier 25 on injection visits, template changes and a feedback loop in which coders query rather than simply release. These priorities shape Milestone Two.

Conclusion

Nearly half of the sampled claims at Sawtooth were not supported as billed, and the reasons are ordinary ones: untrained clinicians, permissive templates and no feedback. None of the records suggested an intent to deceive, but the practice can no longer say it did not know. The compliance program that follows must start where these records point.

References

Balusu, S. S., Patel, M. S., Williams, A. J., Kalkman, J., Latack, K. A., & Day, C. S. (2026). Coding and billing education with new documentation guidelines: Investigating orthopedic provider confidence and accuracy. Journal of Healthcare Management, 71(5), 335-346. https://doi.org/10.1097/JHM-D-24-00228

Burks, K., Shields, J., Evans, J., Plumley, J., Gerlach, J., & Flesher, S. (2022). A systematic review of outpatient billing practices. SAGE Open Medicine, 10. https://doi.org/10.1177/20503121221099021

Tsou, A. Y., Lehmann, C. U., Michel, J., Solomon, R., Possanza, L., & Gandhi, T. (2017). Safe practices for copy and paste in the EHR: Systematic review, recommendations, and novel model for health IT collaboration. Applied Clinical Informatics, 8(1), 12-34. https://doi.org/10.4338/ACI-2016-09-R-0150