Mr. Jones, A Patient Of Dr. Brown's Arrives For His Annual Wellness Exam
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Imagine the following scenario: Mr. Jones, a patient of Dr. Brown’s arrives for his annual wellness exam. Mr. Jones feels great, with no complaints. When he sees Dr. Brown, Dr. Brown spends 15 minutes reviewing his last office note. He listens to Mr. Jones’ heart and lungs, checks his ears, eyes, nose, and throat, palpates his abdomen, and looks at his extremities for swelling. Everything looks fine. Reimbursement for annual wellness visit has a typically billable value of 50 dollars. However, Dr. Brown documents Mr. Jones office visit as an extended visit, not an annual wellness; that visit now billable value of more than 100 dollars. The medical coder submits the bill as documented. This is up coding.
Up coding, has serious consequences. If a facility is caught up coding, it can result in extensive fines and fees, running up into the thousands. Furthermore, depending on the seriousness of the situation, deliberate verse accidental, it can result in the loss of participation in government healthcare programs, such as Medicare and Medicaid. To make matters worse, it is ridiculously easy to prove it; all the government needs to do is show that violation has occurred (Caesar, 1996).
In Dr. Brown’s case, he was running late, patients had been waiting over an hour, and he simply marked the wrong box. That day he marked 1 out of 27 patients he saw, with the wrong procedural code. Eventually, Dr. Brown was “nailed” up coding. “Eventually?” So, how is one, eventually