jmontone_HIM1257 Module 06 Assignment Worksheet_121523_revised

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Rasmussen College, Saint Cloud *

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HIM1257

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Mechanical Engineering

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Jan 9, 2024

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HIM1257 Ambulatory Coding Module 06 Written Assignment: H ow Correct Coding affects Billing and Reimbursement Instructions: Each scenario is worth a potential 10 points. Points in parentheses are for each scenario. This assignment is worth a total of 30 points.  Read each scenario and review the assigned codes. (The 3m encoder’s APC finder is useful to identify any billing edits.)  Identify the error in the claim and explain why it might be improperly paid or denied (3 points)  Describe how this error could be remedied (3 points)  Explain in a few sentences the impact of reporting the code(s) incorrectly. Think about reimbursement, compliance, coder performance, reporting, and any other processes that are affected by coding and claim submission. (4 points) 1. A 90-year-old white female with a known history of hypertensive kidney disease is referred by her regular internal medicine physician for a cystoscopy. She was treated for urinary tract infection but microscopic hematuria is persistent. A cystourethroscopy was performed under general anesthesia. The urologist removed a small 0.6 cm tumor from the lateral wall of the bladder. The specimen was sent to pathology. A squamous cell carcinoma was diagnosed. The reported diagnosis codes were: R31.21, C67.2, I12.9, N18.9 The reported procedure codes were: 52000, 52234  Identify the error in the claim and explain why it might be improperly paid or denied (3 points)  Describe how this error could be remedied (3 points)  Explain in a few sentences the impact of reporting the code(s) incorrectly. Think about reimbursement, compliance, coder performance, reporting, and any other processes that are affected by coding and claim submission. (4 points) Procedure code 52000 should not be reported, and cannot be paired with CPT code 52234, because it is related to and part of this procedure. 52000 is described as a separate procedure and would only be reported if it was unrelated to the other procedures and modifier -59 would be appended. Improper coding leads to improper billing. Services are denied for multiple procedures when there is a single more comprehensive code and, in this case, you only report 52234 as the more comprehensive code. 2. A 55-year-old female with a known history of varicose veins in the left leg presents to the clinic complaining of left ankle pain. No know injury is recalled. A short leg splint is placed for the

patient’s comfort and to provide stability. She is advised to follow up in one week if there is no improvement. The reported diagnosis codes were: S93.402A, I83.92 The reported procedure codes were: 29515, 73090  Identify the error in the claim and explain why it might be improperly paid or denied (3 points)  Describe how this error could be remedied (3 points)  Explain in a few sentences the impact of reporting the code(s) incorrectly. Think about reimbursement, compliance, coder performance, reporting, and any other processes that are affected by coding and claim submission. (4 points) In this scenario, you would only report 29515 . CPT code 73090 is for RADEX Forearm 2 views, which is not a procedure listed in this scenario. Reporting incorrect codes or additional codes for procedures not documented in the medical record causes billing and reimbursement errors. These mistakes can result in claim denials, reduced reimbursement, and potential compliance issues, including audits, fines, and penalties. Ensuring accurate code assignment is crucial for maintaining the integrity of the billing process and avoiding financial and legal consequences. In my opinion, this would be a situation where you would need to query the physician to see why or if the forearm was x-rayed. The documentation only states that the patient presented to the clinic with left ankle pain and a history of varicose veins. 3. A 67-year-old male established patient presents to the clinic complaining of chronic low back pain. The patient also noted urinary hesitation and cloudy appearing urine. A urine culture is ordered. The patient is advised to take acetaminophen for the pain and follow up in 3 days unless symptoms worsen. The physician spent approximately 15 minutes with the patient with low level medical decision making. The reported diagnosis codes were: M54.5 The reported procedure codes were: 99213, 87086  Identify the error in the claim and explain why it might be improperly paid or denied (3 points)  Describe how this error could be remedied (3 points)  Explain in a few sentences the impact of reporting the code(s) incorrectly. Think about reimbursement, compliance, coder performance, reporting, and any other processes that are affected by coding and claim submission. (4 points) The E/M code should 99212 because the physician only spent 15 minutes with the patient whereas the E/M code 99213 would be reported if the physician had spent 20-29 minutes with the patient.

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