Erma Care Case Study

As a biller or coder, if it is not documented, it didn't happen that needs to follow to be able to give an excellent service to every patients. Documentation is the key to have an appropriate health patients result including demographics, health issues, and billing. “Consistent and complete documentation in the medical record for every patient is an essential component of providing quality patient care. This documentation is required to record pertinent facts, observations and findings, and must meet certain compliance standards.” If not documented that is not necessary to give any further diagnosis

A typical day in the office includes auditing claims, sending claims to insurance companies, and working denials. Auditing claims is making sure what the physician coded for is documented and that the codes are correct. Each day I review the physician 's documentation against the codes they put into our system for their patient’s visit. At times when the documentation does not match what is coded, I query the physician and ask them to re-review their assessment and documentation. Below in the section, “Issues and How They Were Resolved” is a couple of examples of when the physician was contacted. I audit multiple claims a day and it is important that each one is suitable before it is sent to the insurance company.

Identify the correct diagnosis (ICD-9-CM) code(s) for the outpatient hospital visit for patient Josh Blake:

21. Report any unusual or major changes in your patient’s health, cleanliness, physical care, actions and

It is accurate that the last sentence of the first paragraph of your report you stated “This evaluation was requested for diagnostic clarification and treatment planning”?

I wanted to let you know we had Dr. Cohen call us twice yesterday unsatisfied with the way the report was read. He spoke with Dr. Rotblat who had read the report and ask him to change certain things that he wasn't happy with. But Dr. Rotblat told Dr. Cohen to call our front desk and ask them to get another radiologist to read it. I called Dr. Cohen today to get more information about the situation and know what could we do to help resolve the situation and make it better as well I apologize to him for the way the situation was handled. He explained certain words and Diagnoses in the report was incorrect and not true. So We had Dr. Panasci do an Addendum. I did follow up with Dr. Cohen office and spoke to Julie left

Responsible coder collects post and manages account payments, submitting claims and keeping in touch with insurance companies. If patient information is coded incorrectly, or incomplete it could leave an impact that can be brought to a claim. Inaccuracy in patient information can lead to denials, none payment and investigation. It is important to get all the details right by verifying insurance coverage properly. Make sure that the patient’s name is spelled correctly, date of birth and sex of the patient are correct; and most important be sure that the policy number is valid.0verall before claims are sent, documentation should be in order and the claim should be checked for completeness and accuracy.

As a practicing doctor it is important to episode with patience so they will be no missed diagnosis, as there was in the case with a patient who had shortness of breath. The doctor informed there was too much pressure from her weight pressing on her chest. It turns out that the patient was suffering from several blog clots in her lungs. If the doctor was to look beyond there obesity, he might have diagnosed her

One of the biggest challenges of the local health care system is that small and local hospitals are finding the hardest time to anticipate customized drugs as they are not the major markets of the big pharmaceutical institutions. Apollo Care founder James Krogman, along with Jarred Dudding recognizes these inherent inefficiencies and addresses this by providing Missouri hospitals with solutions tailored for their needs. This attention to the needs of minor markets and small customers sets Apollo Care apart.

The only goal of this meeting is to disclose the event and answer any questions the patient and/or family may have. The physician will describe what actions the hospital has taken in response to this event, any future actions that will take place, and what policies were reviewed while investigating this error. The physician and designated hospital staff member will also disclose contact information for future communications with the patient and/or family members. It is the physician’s discretion to initiate future communications and face to face meetings with the patient and/or family

I think you have chosen a very interesting topic. I also am a ER nurse, and I truly hate having to put my kids thru such a traumatic even , although I do have good bedside rapport with my kids, I still don’t like putting them in harms way, by causing them pain along with getting them so upset by getting a IV. I have tried the EMLA also, but like you have found the time it takes to actually work takes to long, and many times I need labs done now. I am very interested in hearing more about this “needle-free” jet injection. I have not heard of such technology, and would welcome it in my own ER practice. I look forward to seeing and reading more about your idea.

Differential diagnoses are developed by a clinician upon learning of the chief complaint. One must begin to develop the possibility of potential diagnoses mentally to guide the care provided to the patient. These potential diagnoses are developed by the care provider and are often based on one’s past clinical experiences, awareness of the illness and a clear understanding of the patient’s complaint (Goolsby & Grubbs, 2014). The care provider with experience may develop these diagnoses independently and others with less experience may utilize evidence-based resources and clinical guidelines to aid in this process (Goolsby & Grubbs, 2014). The process for reaching a final diagnosis requires further investigation and use of physical assessment

It is nearly impossible to avoid clinical denials entirely. Therefore, the health information management (HIM) department should have strong procedures built as a defense against clinical denials. Ensuring the claim is sent to the payor appropriately is complicated since coders “must not only ensure they are within the parameters of official coding guidance, but also they must review the record to justify the clinical significance” (Brownfield et al., 2014). For example, universal coding guidelines in ICD-10-CM explain that coders should not assign codes for signs and symptoms with an established diagnosis if the signs and symptoms are integral to the established diagnosis. For example, if the patient is experiencing lower back pain and the

Great post. I totally agree with your chosen diagnosis. In scenario 2, patient complained of dyspnea, hemoptysis and chest pain. On assessment, patient’s respiratory rate was 32 and labored; pulse 112, O2 sat 90%, skin cool and sweaty, heart rate was irregular. He also has 2+ edema on right calf, erythema, warmth, and tenderness. He also appeared anxious. These are classic signs of PE. Also, the NP ordered specific labs for the patient from the information and assessment she conducted. Diagnostic reasoning is a scientific process in which the practitioner suspects the cause of the patient’s symptoms and signs based on previous knowledge gathers relevant information, select necessary tests and recommend therapy (Dains, Baumann, & Scheibel,

Responsible coder collects post and manages account payments, submitting claims and keeping in touch with insurance companies. If patient information is coded incorrectly or incomplete it could leave an impact that can be brought to a claim. Inaccuracy in patient information can leads to denials, none payment and investigation. It is important to get all the details right by verifying insurance coverage properly. Make sure that the patient’s name is spelled correctly, date of birth and sex of patient are correct; and most important be sure that the policy number is valid.0verall before claims are sent, documentation should be in order and the claim should be checked for completeness and accuracy.