Question

The Medicare HMO plan sent the practice an RA as shown in Figure 16.1.

Locate the claim for Wendy Walker in the remittance advice (RA). Notice that the claim has been denied.

 

1. What reason is given for the rejected claim? What procedure has been billed in the claim?

 

2. Refer back to the encounter form for Wendy Walker in Claim Case Study 15.1. Does the encounter form contain the same procedure code that is listed in the RA?

 

3. Refer next to the patient information form for Wendy Walker in the same case. What is the date of her signature on the patient information form? Do you think she is a new or an established patient?

 

4. On checking your files, you confirm that Wendy’s visit on October 3 was her first visit to the practice. What procedure code will you use to correct the claim you created for her on 10/03/18?

 

5. In addition to the procedure code, what other item on the claim will you need to change? (Hint: You may need to refer to Table 15.1.)

 

6. Assume that you have corrected the claim and resubmitted it. How much do you think Medicare will pay her provider for the visit? Note that Wendy has already paid her copayment for the visit and that her Medicare HMO pays for 100 percent of covered services.

 

 

Locate the claim for Andrea Spinelli in the same RA (Figure 16.1). Notice that her claim has also been denied.

 

1. What reason is given for the rejected claim? Look up the diagnosis code connected with the claim (Dx H61.23) in a list of ICD codes. What diagnosis does it stand for?

 

2. Refer back to the patient information form and encounter form for Andrea Spinelli in Claim Case Study 15.7. Based on the patient information form, what is the patient’s reason for the visit?

 

3. Refer to the Dx box on the encounter form. Notice that the description is correct but the code is not. What diagnosis code is required to correct the claim you created for Andrea Spinelli on 10/06/18?

 

4. Assume that you correct the diagnosis code on the claim and resubmit it. How much do you think Medicare will pay her provider for the visit? Note that Andrea has already paid her copayment for the visit and that her Medicare HMO pays for 100 percent of covered services.

 

Answer 1

Patient: Wendy Walker

1. Incorrect procedure code; 99214

2. Yes

3. 10/5/16; new

4. 99204 (LIV, New Patient)

5. The charge amount, $103

6. Since the plan pays for 100 percent of covered services, and Wendy has already paid a $10 copay, her Medicare plan will likely pay $93 ($103 charge, minus her $10 copay).

Patient: Andrea Spinelli

1. The diagnosis is inconsistent with the procedure; 394.0, Mitral Valve Stenosis.

2. Cerumen in ear

3. Dx H61.23

4. $24 ($34 charge, minus the $10 copay)