Question

Notice that of the three procedures listed, one has been denied.

 

1. What reason is given in the RA for the rejected procedure? What is the description of the procedure?

 

 

2. Refer back to the encounter form for Lakshmi Prasad in Claim Case Study 15.4. Does the encounter form contain the same procedure code that is listed in the RA?

 

 

3. Refer next to Lakshmi Prasad’s patient information form. Confirm that Lakshmi is an established patient. Also verify the reason for the visit as described on the patient information form.

 

 

4. Next, check the patient information form for Lakshmi’s date of birth. Based on her age on the patient information form, what correction should be made to the encounter form and claim information?

5. You can actually use the CMS-1500 form below to complete this secondary claim. During the electronic submission of Lakshmi Prasad's 10/06/2029 claim to the insurance company, the office visit procedure code was changed. The claim must be re-submitted with the appropriate procedure code.

Answer 1

Patient: Lakshmi Prasad

1. Incorrect procedure code; Preventive Visit, EP, Age 65+

2. Yes

3. The signature date indicates that Lakshmi is an established patient, and the reason for the visit is “routine examination.”

4. The procedure code and amount should be changed from 99396 (Preventive Visit, EP, Age 40-64) $106 to 99397 (Preventive Visit, EP, Age 65+) $118.