Homework Question on Medical Codes and Audits
Identify the evaluation and management codes that tend to have the highest rate of denials and claim issues, and discuss why you believe those codes pose a problem. What, if anything, could be done to improve this issue?
Place of Service
Discuss the difference between two places of services, including the appropriate codes, and identify why it is important for place of service to be correct for coding purposes.
Discuss upcoding and downcoding and provide an example of each. Make sure to discuss the consequences of each coding errors. Be sure to identify at least two different errors and their consequences in your initial post. Before you submit your initial post, review posts from your fellow students and try to avoid repeating the errors already listed by them.
In your follow up posts, discuss if you agree with the consequences and suggest possible solutions that would help alleviate the issues.
Compliance, Audits, and Medical Billing – Discussion
Discuss:Medicare has scheduled a coding and billing audit with your medical practice. As the medical office manager, you must coordinate and create a plan for your employees to prepare for the audit. Discuss the main purpose of the audit, what the office must do to prepare for the audit, and what happens if non-compliance is found. Also, what should be done throughout the year to ensure compliance with regulation?
Medicare, Medicaid, TRICARE and Workers Compensation – Discussion
One of the MAs’ responsibilities can be to educate patients about their particular insurance plan. Sarah just walked in to the front office and is very distraught about her bill and doesn’t understand why she received this bill and what she has to pay.
- Choose the insurance plan you want Sarah to be enrolled in: Medicare, Medicaid, TRICARE, Workers’ Compensation.
- Choose her reason for the initial medical appointment and correctly use the necessary codes and compensation entitled by the insurance she is enrolled with.
- Tell us how you would explain her insurance benefits, rights, costs, and billing under her particular plan.
EOB (Explanation of Benefits) and Payment Adjudication: Refunds and Appeals – Discussion
You just received the EOB for Violet Sims, a patient in your medical office. What information should be checked before posting payment and why? If an error has been identified on Violet’s EOB, what are the steps to locate and correct the error? You notice that Violet’s claim has been denied, though it should have been paid. What should you do to obtain payment and why?
Min of 150 words for each question
Homework Answer on Medical Codes and Audits
Evaluation and management (E/M) codes refers to a medical coding process that uses five digits to represent services, procedures and diagnosisin order to get paid by Medicare and Medicaid(Powers, 2011). Decision Health puts initial patient visits (99221-99223) and subsequent visits (991231-99233) at the top of E/Ms having the highest denial rates.This can be caused by contradiction between the chief physician documentation in the chief complaints and the documented exam elements in case of a patient’s complaint. This attracts the attention of an auditor who may halt the payment pending further investigation. This can be remedied by use of electronic health records systems which ensures the integrity of medical records by making it easier to import old data of apatient’s documentation into a current record.
Another reason could be lack of documented history to establish the patient’s condition, change or progress. Medicare requires physician to document the aforementioned for medical-decision making which is used for code selection. The solution to this problem could be to write a good interval history for each patient. The denial can be caused by review of system (ROS) lacking the initial encounter notes thus the physician gets paid less. This can be solved by use of a good ROS for initial encounters.
Place of service codes refers to a two digit code used by a physician to show the place where a service was offered. For example code 11 which is termed office indicates that a service was offered in an office which means not in a hospital, military or skilled nursing facility or a community health facility where the physician makes routine calls. Code 12 which termed home shows that the location where the services were offered is not a hospital or facility. These codes are vital as they ensure that the physician is not incorrectly paid for the overhead portion of the payment if services are offered in a facility.