Question

Consider the following patient scenario:

“Agnes, an 82-year-old female, is 168.02 cm. (1.6802 m.) in height and weighs 62.36 kg. She has longstanding type II diabetes mellitus and was diagnosed with ESRD in 2008, and has been on HD since that time. Since 2015, she has been receiving outpatient dialysis treatments at a facility that qualifies for the LV adjustment, because it has never had a treatment volume exceeding 4000 treatments since it opened in 2005. On April 1, 2015, Agnes was hospitalized with bacterial pneumonia and remained hospitalized until April 6. She resumed outpatient dialysis on April 10. Agnes was declared free of bacterial pneumonia on May 5, 2015, after post-hospitalization treatment with antibiotics. Agnes received dialysis for a total of 20 days in April 2015. The facility submitted reimbursement claims for dialysis treatments or dialysis treatments given to Agnes during the month of April; however, the facility failed to report the co-morbidity of bacterial pneumonia.”

You are in-charge of billing and coding at the healthcare facility where Agnes was treated. Because of the inexperience of coders at your facility, Agnes’s medical severity was not properly captured in the documentation submitted for reimbursement. For example, her comorbid condition bacterial pneumonia was not included.

Discuss the implications of not accurately capturing the patient medical conditions on reimbursement. How does this case relate to the negative effects discussed in the following article?

The Five Negative Effects of Medical Coding and Billing Errors, Medical Practice Management Resources, May 2018.

Answer 1

Therapeutic charging blunders can endanger a patient's capacity to get treatment or be repaid for costs. It can influence their life from multiple points of view, as they may lose essential medicinal administrations, benefits, and their capacity to see authorities and get rehabilitative administrations. The interest procedure they should experience can be intricate, tedious, and, if legitimate activity is all together, costly. In addition, they may have other lawful strategy of act if the mistake that caused their issues is associated with the restorative supplier and therapeutic protection assert blunders.

Continued charging mistakes, sketchy charging rehearses, and conflicting or deficient documentation can trigger inquiries concerning extortion. The legislature is centered on restorative misrepresentation, as the FBI assesses that the cost every year is in the trillions of dollars. A misrepresentation examination will charge your opportunity, wallet, and nerves. Some of the time the purposes behind blunders are totally considerate, however any whiff of doubt can bring a full investigative exertion into your life, disturbing your therapeutic practice and putting your employment in danger.

Lawful activities related with medicinal protection cases can originate from any of different substances, including state or government law requirement, insurance agencies, and people, including patients. This most dire outcome imaginable is a reality for some specialists.

Every year for as long as three years, the FBI has charged substantial gatherings of social insurance experts with having submitted an enormous quantity of dollars in Medicare extortion; in addition to hundreds more have been charged independently every year. Leaving the inquiry or trace of conceivable misrepresentation out of your restorative protection charging and coding process is vital.