Question

The last 2 experts were answered too long and not focused on dot questions. Keep shorter.

Here’s a sample of MA communication w/provider:

“Dr.Hi I have noticed today that you indicated a level 1 office visit for patient A,B,C when ur documentation in their health record shows that u did a level 4 office visit on A,B,C. Im wondering if u accidentally marked the wrong box on the superbill. I wanna make sure that u get paid for the service u provided and by submitting these claims as a level 1 office visit you are downcoding ur claim”

The answer should be like this

You are going to pick one coding case that reflects a case of upcoding or downcoding. Once you select a case, the following is what I need to see listed in your initial discussion post for full credit: Identify if this case is an example of upcoding or downcoding. . Explain how you identified this case as upcoding or downcoding .Explain how this can affect reimbursement. Provide an example of how you would communicate this discovery to the provider in a professional manner Case Onel Samantha Smith went to her doctor because she was experiencing nightmares that woke her up several times through the night. She experienced day time fatigue and had a hard time focusing on her daily activities. She also feared going to bed at night thinking she would have another episode. She wanted her doctor to refer her for a sleep study During the examination the office staff discovered that Samantha's insurance would not pay for a sleep study with a diagnosis of nightmares or fatigue, but would if the patient had sleep apnea. In order to get a sleep study covered under Samantha's insurance, the provider decided to place the diagnosis of sleep apnea in Samantha's health record even though she did not have that diagnosis. . 18 MacBook Pro F3 F4 FS F6 F7 F8

Answer 1

Hi Dr. X,

I lately distinguished about my diagnosis put on the record about sleep apnea. Though I know as per our discussion last visit, I was told that it was nightmares and fatigue. I do comprehend your apprehension approximately me getting through for sleep study and most probably that my insurance pays it rather than me paying it out of my pocket. But I guess that would just be non-diligent. I did go through some compliance policies regards to this up coding whether this scenario come under this category. I will list them out for you for better understanding.

The OIG furthermore recommended that providers realize the going with parts:

-Advancement and scattering of created lead benchmarks and methodologies that hoist the mending office's vow to consistence and that area locales of potential coercion, for instance, claims organization and budgetary relationship with various providers.

-Arrangement of a CCO and other consistence staff blamed for working and checking the consistence program and offering an explanation to the mending office's managing body.

-Usage of endless guidance and planning for staff.

-Support of a technique to get therapeutic administrations distortion reports and grumblings, for instance, a hotline, and the change of philosophy to shield lack of definition and sources from striking back.

-Foundation of a system to respond to social protection coercion and abuse claims and reasonable disciplinary exercises against staff who misuse consistence methodologies and laws.

-Utilization of audits and in addition evaluations to track consistence adherence and help diminish issues.

-Examination and remediation of key issues and the establishment of ways to deal with location if staff included are held or finished.

So I would request you to please change the diagnosis or I would have no other option but to cancel my medical record and discontinue my visits to you.

Thank you,

Xyz.