HIM 600 Module 9 Final Project Example

Final Project: Billing What We Document. A Coding Compliance Program Proposal for Sawtooth Bone and Joint

[Student Name]

Southern New Hampshire University

HIM 600: Managing Compliance

Final Project

[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: Billing What We Document. A Coding Compliance Program Proposal for Sawtooth Bone and Joint

Executive Summary

Sawtooth Bone and Joint, the composite 38-surgeon and physiatrist group in Boise, Idaho, bills more than 90,000 office visits a year and has never had a working compliance program. When 60 of its records were reviewed this spring, nearly half of the claims, 29 in all, rested on notes that did not support them. This proposal asks the managing partners to approve a coding compliance program with an independent compliance officer, a standing committee, seven policies, tested training, a risk-ranked audit cycle and a defined response to findings. First-year cost is estimated at about $163,000. The program's goal is simple to state: by the end of 2027, the practice should bill what its notes document, at least 95% of the time, and be able to show it.

Background and Need

The spring review covered claims from April to June 2026, split between return visits coded 99215 and injection visits that also carried a separate visit. In most failed level five notes, talk of a possible operation had been scored as high risk although nothing in the note explained why the operation would be risky for that patient, and several time-based claims gave no total. Most failed modifier claims recorded nothing beyond the choice to give another shot for a known problem. Copied examination text appeared in 28% of notes, sometimes contradicting the assessment. The causes were consistent: no training on the 2021 guidelines, templates that suggested levels and generated full examinations, and no feedback from coders. Burks et al. (2022) named the same three causes in their review of outpatient billing studies, and Balusu et al. (2026) reported that self-rated coding skill among orthopedic clinicians was a poor guide to actual accuracy. The practice also faces two arrangement risks: a brace supplier's offer of free fitting staff, now declined in writing, and the conditions the group's MRI suite must meet to accept its own physicians' referrals.

Program Goals

The program has four goals for its first 18 months. First, raise documentation accuracy for office visit levels and modifier 25 to at least 90% within six months and 95% by the end of 2027. Second, refund every identified overpayment within the federal deadline, including any amount found in the look-back review now under way with counsel. Third, establish every element of an effective program as federal guidance describes it (U.S. Department of Health and Human Services, Office of Inspector General [HHS-OIG], 2023). Fourth, build a culture in which coders and staff raise concerns early and see them acted on.

Structure and Policies

A compliance officer, at half time for two years, reports directly to the three managing partners in quarterly closed sessions and is independent of billing. A committee drawing on two physician subspecialties, administration, billing, coding and therapy approves policies, reviews audits and decides escalations, with outside counsel available. Seven policies address what the review found: documentation and level selection, modifier 25 with injections, copied documentation, coder queries, advanced practice billing, referral and vendor arrangements and overpayment refunds. Clinicians and coders sign each one, and the committee revisits them annually.

Training

All staff complete an hour on the program and the fraud and abuse laws each year. Clinicians spend two hours on visit leveling and same-day injection billing, taught from anonymized notes drawn from Sawtooth's own charts, followed by a test in which each levels five notes; those scoring below 80% repeat the session within a month. Coders also learn to write compliant, non-leading queries. New clinicians are trained before their first claims are released.

Auditing and Monitoring

The committee ranks billing areas yearly by likelihood and impact. Office visit levels and modifier 25 rank highest and receive prospective review for each clinician until accuracy reaches 90% on two monthly samples, followed by quarterly retrospective probes of ten claims. Error rates above 10% lead to a 30-claim discovery sample, and confirmed patterns lead to a statistically valid sample under counsel's direction. Monthly monitoring compares clinicians' visit level distributions, modifier 25 rates and billed hours; Fang and Gong (2017) showed that billed hours beyond what a person could work can signal overbilling. An outside firm audits 100 random claims each year.

Response to Findings

Overpayments are calculated claim by claim and refunded through each payer's process. Matters that may involve more than error, such as kickbacks or continued billing after a clinician was told it was unsupported, go to counsel to decide whether disclosure to federal authorities is required. Every finding produces corrective actions, each assigned to one person with a due date and a test of success, and clinicians receive private feedback on their own notes. Re-audits at three and six months confirm whether corrections held.

Culture and Reporting

An outside hotline, a non-retaliation policy signed by the partners and a quarterly note to staff on what concerns led to change make up the reporting system. Policies alone do not change behavior. Kaptein (2011) tied lower rates of misconduct to workplaces where people know the standard, watch their leaders keep it and can talk through hard cases without risk. For that reason, the partners will be audited like everyone else, audit accuracy will appear in every physician's annual review alongside productivity and the compliance officer will ask coders for concerns each month rather than waiting for reports.

Timeline

Table 1 shows the implementation schedule. The first 90 days focus on actions that stop new errors, because each month of unchanged templates adds claims that may later need to be refunded.

Table 1. Implementation Timeline

Note. Dates run from the partners' approval.

Budget

First-year costs are estimated at about $163,000: $62,000 for the half-time compliance officer's salary and benefits, $48,000 for a coder dedicated to prospective review, $22,000 for outside counsel, $18,000 for the outside annual audit and the look-back sample review, $8,000 for template and edit changes and $5,000 for the hotline and training materials. These costs exclude refunds, which are owed whether or not the program exists. Against them, the practice should weigh the cost of continuing to bill unsupported claims for which it now has notice and the protection that a documented program gives if a payer or regulator asks.

Measures of Success

The partners can judge the program by six measures reported twice a year: accuracy of office visit levels, accuracy of modifier 25 claims, the share of notes with copied examination findings that contradict the assessment, the percentage of clinicians who passed the coding test, the number of concerns raised and resolved and the share of identified overpayments refunded on time. Targets for the first two are 90% at six months and 95% by the end of 2027. A rise in reported concerns will count as a good sign in the first year.

Conclusion

Sawtooth's records show that the practice has been billing more than its notes support, not through any scheme but through untrained habits and permissive systems. This proposal gives the partners a program sized to a 38-physician group that fixes those causes, pays back what is owed, keeps watching and makes it safe to speak up. Approving it now is the clearest way for the practice to show that it acted once it knew.

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

Fang, H., & Gong, Q. (2017). Detecting potential overbilling in Medicare reimbursement via hours worked. American Economic Review, 107(2), 562-591. https://doi.org/10.1257/aer.20160349

Kaptein, M. (2011). Understanding unethical behavior by unraveling ethical culture. Human Relations, 64(6), 843-869. https://doi.org/10.1177/0018726710390536

U.S. Department of Health and Human Services, Office of Inspector General. (2023). General compliance program guidance. https://oig.hhs.gov/compliance/general-compliance-program-guidance/