Importance of Clinical Documentation in Coding and Reimbursement Practices
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Importance of Clinical Documentation in Coding and Reimbursement Practices
Module 01 Assignment – Importance of Clinical Documentation in Coding and Reimbursement Practices
Instructions: Read each scenario and answer the associated questions. Be sure to write your answer beneath each question, using complete sentences, reflecting proper spelling and grammar.
Scenario 1:
A patient presents to the Emergency Room with severe shortness of breath, extreme lethargy, and intermittent loss of consciousness. The patient is unaccompanied and unable to provide past history of diagnoses or treatments. According to the EHR, the patient had been admitted to the facility for a 48-hour observation 3 months ago. Upon review of the patient’s medical record, the History and Physical and Discharge Summary were not available in the medical chart. The Emergency Room provider attempted to contact the patient’s attending physician and learned the provider was out of the country on vacation.
Instructions: State your interpretation in response to the following questions. Provide support for your rationale based on lesson content.
1. What are the risks to the patient due to the missing clinical documentation?
2. What is the impact to coding due to the incomplete clinical documentation?
3. What is the impact to billing and reimbursement due to the incomplete clinical documentation?
Scenario 2:
The Billing Department has received a denial of payment for an inpatient hospitalization that had an extended length of stay of 10 days. The patient received a number of radiological interventions and treatments for a diagnosis that had a typical length of stay of 5 days. The provider is being asked to explain the lengthy and costly hospitalization in appeal of the denial. Of note, the hospital is in the process of transitioning to a full EHR. Upon review of the patient’s electronic medical record, it is noted that there are a number of exacerbated chronic conditions that were present on admission and were treated during the hospitalization. The provider explained that the chronic conditions delayed the healing process. Coding was engaged to review the electronic documentation and the paper charts to ensure all possible diagnoses and procedures were coded.
Instructions: State your interpretation in response to the following questions. Provide support for your rationale based on lesson content.
1. Determine a possible explanation for the denial of charges based on the extended length of stay?
2. Was this a failure on the part of the provider to fully document the patient’s conditions and treatment—why or why not?
3. Was this a failure on the part of coding to read the entire patient record when assigning the codes—why or why not?
4. Was there a failure on the part of billing to ensure that the claim was clean prior to submitting for payment—why or why not?
Scenario 3:
A patient has requested a copy of her clinical chart to be released to a specialist treating a newly diagnosed condition. The specialist is interested in learning about any previous diagnoses, medications, and allergies the patient has had documented in the past. Upon review of the patient’s record, she notices that the patient has a diagnosis of a poorly functioning thyroid, but there is no evidence of treatment or medications. In discussion with the patient, the patient indicates she was never diagnosed with a thyroid problem.
Instructions: State your interpretation in response to the following questions. Provide support for your rationale based on lesson content.
1. What are the possible reasons for this diagnosis appearing in the patient’s medical record?
2. What could have happened in the patient registration process to cause a problem with the clinical record?
3. What could have happened in the coding process to cause the problem?
4. If you were the patient with a wrong diagnosis on your chart, how would that impact your future relationship with the health care provider?
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