Note: This is a collaborative exercise involving a minimum

Note: This is a collaborative exercise involving a minimum of 2 key… Note: This is a collaborative exercise involving a minimum of 2 key players for each scenario Scenario 1 During the process of preparing an inpatient claim for submission, an edit was encountered indicating there were surgical charges on the claim, but there were no ICD-10-PCS codes to correspond with any of the surgical charges. Explain Which Revenue Cycle Key Player(s): 1. Determines if the surgical services were performed for the patient 2. Determines if the documentation in the medical record accurately reflects the services received by the patient 3. Determines if additional codes needed to be added to the patient’s account Scenario 2 The Release of Information (ROI) vendor reports to the HIM Department. In response to a request for records, the ROI Vendor disclosed a copy of the patient’s records to the patient. Upon receiving the requested records, the patient discovered that the records did not reflect her encounter at the facility. The patient contacted the ROI department indicating the records are not her records, stating she never received the treatment/services documented on that date of service; in fact, she was not a patient on that date. Consider the possible reasons for the documentation of the incorrect information on the patient’s medical record. Explain Which Revenue Cycle Key Player(s): 1. Determines the accuracy of the patient demographics attached to the patient’s medical record 2. Would be responsible for correcting the master patient index (MPI) 3. Would be involved in retrieving/destroying the copies of the incorrect patient records and reprocessing the request for records with the corrected medical records Scenario 3 In March, a revenue cycle professional was attempting to code an ambulatory care visit when the professional noted a new CPT code is now available as of January for the service provided to the patient. The charge information entered for the patient’s date of service does not contain a charge code with the new CPT code. Explain Which Revenue Cycle Key Player(s): 1. Would be involved in reviewing the charge information and determine if the new CPT code should be added to the charge master 2. Would be involved to provide clinical information relative to the potential addition of a new charge code using the new CPT Code 3. Would be involved to complete the process of finalizing the account for billing if the new charge code was created and added to the patient’s account Scenario 4 The Hospital Administrator (CEO) received the end-of-month revenue cycle reports and noted that there is a significant increase in the Discharge, Not Final Billed (DNFB). The CEO would like to have an update on the status of DNFB with an action plan for improvement. Explain Which Revenue Cycle Key Player(s): 1. Would be involved in evaluating the DNFB status. 2. Explain two possible reasons for an increase in the DNFB Scenario 5 Review of a patient’s record during a hospital stay reveals that the patient’s admission diagnosis indicated suspected sepsis. The subsequent hospital medical record documentation does not reveal any notes indicating the condition was treated or resolved. Prior to coding, the documentation discrepancy will need to be resolved. Explain Which Revenue Cycle Key Player(s): 1. Would be involved in reviewing the patient’s record for accuracy of the documentation prior to sending the chart for coding 2. Describe the role of coding in this scenario 3. Explain the role of the provider regarding their documentation Scenario 6 Two days ago, an elderly Medicare patient was admitted as an inpatient for treatment of a hip fracture. Following assessment and workup, the attending physician determined that the patient was not a good surgical candidate. Staff are preparing to transfer the patient to a Skilled Nursing Facility (SNF) for rehabilitation. Upon case review, however, it was noted that the patient did not meet the three-day rule for transfer to an SNF. The patient needs to be evaluated to determine if criteria is met for an extended stay prior to transfer. Explain Which Revenue Cycle Key Player(s): 1. Would be involved in the case review and length of stay determination 2. Describe the role the physician plays in this scenario 3. Explain the importance of documentation in this scenario Scenario 7 The HIM Department of an acute care hospital received a notice that the payer performed a post-payment audit indicating there has been an overpayment for services performed. The notice states that a reviewer evaluated the documentation and did not find medical necessity for the Magnetic Resonance Imaging (MRI) procedure that was performed during the patient’s hospitalization. The facility has 30 days to respond to the notice or the payer will rescind the overpayment amount. Upon reviewing the patient’s medical record, the MRI report is missing a reason for the test and the results indicate the MRI was normal. The reason for the test is documented on the physician order for the MRI but was not included on the report. Explain Which Revenue Cycle Key Player(s): 1. Would be involved in resolving the documentation of medical necessity issue 2. Describe what needs to be done to demonstrate to the payer that medical necessity for the procedure is present in the chart. 3. Explain the role coding plays in this scenario if new information is now available. Arts & Humanities English English Literature HIM 2133 HIM2133

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