253 522 bilateral reporting subdomain va3 adhere to

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253 5.22 Bilateral reporting Subdomain V.A.3 Adhere to the legal and regulatory requirements related to the health information management Subdomain V.B.1 Construct and maintain processes, policies, and procedures to ensure the accuracy of coded data based on established guidelines A recent audit of hospital accounts with bilateral cataract procedures coded showed the following: 35 accounts coded 66984-RT Unit of service 1 66984-LT Unit of service 1 172 accounts coded 66984-50 Unit of service 1 7 accounts coded 66984 Unit of service 1 66984-50 Unit of service 1 2 accounts coded 66984 Unit of service 2 Develop a coding procedure for bilateral cataract procedures that will meet compliance under the National Correct Coding Initiative. Answer Per NCCI instructions, bilateral procedures for hospitals should be coded once with a modifier of 50 and reported on a single claim line with one unit of service. (Hazelwood and Venable 2016, 236; CMS 2015) References Centers for Medicare and Medicaid Services. 2015. NCCI Policy Manual for Medicare Services. nationalcorrectcodinited/ Hazelwood, A. and C. Venable. 2016. Reimbursement Methodologies. Chapter 7 in Health Information Management: Concepts, Principles, and Practice , 5th ed. Oachs, P. and A. Watters, eds. Chicago: AHIMA.
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254 Copyright ©2017 by the American Health Information Management Association. All rights reserved. 5.23 Coding review Subdomain V.D.1 Identify discrepancies between supporting documentation and coded data Analyze the scenario below and identify the errors in coding based on the documentation. H&P A 63-year-old woman is admitted with severe, unrelenting headache. CT scan in ER shows an area suspicious for a brain tumor. The woman is admitted to control pain and identify source of primary. She is a diabetic with hypertension. She smokes a pack of cigarettes a day and has for the past forty years. There is a family history of breast cancer with her aunt and sister. Patient will undergo an MRI of the brain and CT of chest and abdomen in hopes of identifying primary source of tumor. Consult This 63-year-old white female is complaining of numbness and tingling to her feet. She is diabetic, type I, with noncompliance with her insulin treatment. She states that she takes half of the required dosage as it is difficult for her to afford her medications. Examination of extremities is indicative of diabetic neuropathy. Have stressed with the patient the need for her to strictly follow her insulin regimen, and follow up for additional tests as an outpatient. Patient needs to have annual foot and eye exams. Progress Note I Patient having CT scans this morning. Will consult with radiology and proceed with recommendations once those results are read. Progress Note II Appreciate consult on diabetic management. Will echo consultant’s call for compliance with medication.
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  • Summer '14
  • Electronic health record, American Health Information Management Association

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