Case Study 3 Medicolegal Considerations

Case Study 3 Medicolegal Considerations

As an advanced practice nurse (APN), you will be responsible for identifying the ICD-10 diagnosis code, CPT code for procedures, and the E&M code for billing of services. Most nurses have not been involved in the coding of diagnoses or procedures, so these systems are probably unfamiliar to you. In this discussion, we will explore all three coding systems.

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International Classification of Disease, 10th Edition, (ICD-10) is the system used to identify the diagnosis for the patient. The system is very specific and selecting the correct code can facilitate the approval of procedures as well as correct billing of services.

Current Procedural Terminology (CPT) are codes that identify procedures that have been completed or tests that are requested. Most CPT codes are related to what is considered appropriate ICD-10 codes. For instance, you would not code a bronchoscopy 0BJ08ZZ and relate it to a diagnosis code of low back pain M54.5. The reimbursement would probably be denied because the diagnosis and procedure do not correlate.

Evaluation and management (E&M) codes are used to determine the complexity of services provided to the patient. Specific documentation must be included in the patient visit note to support the E&M code billed. Improper coding, undercoding, or overcoding can have serious implications for patients, providers, and the provider’s care setting. For this Discussion, you will examine potential coding issues in case studies and consider the medicolegal responsibilities

Case Study 3 Medicolegal Considerations

Samantha Smith is an APRN that wrote this note on a patient in the hospital.

Name: Mr. Xxxxx

Patient and wife in to review the evaluation for SIADH (secretion of inappropriate diuretic hormone). His sodium is now corrected to 136 with water restriction.
CT shows old right frontal infarction which he denies having any symptoms of. There is mild cerebral atrophy consistent with age.
CT of chest shows 2 mm nodule in right apex, possible granuloma.
CT abdomen unremarkable.

Impression:

1. SIADH, improved
2. Pulmonary nodule, small
3. Frontal CVA, asymptomatic
4. Rule out macro vascular disease

Plan:

1. Monitor pulmonary nodule with repeat CT scan in 6 months
2. Pulmonary medicine consult
3. Neurology consult. He will schedule
4. Carotid duplex study
5. Continue fluid restriction

Samantha, the APN, billed Medicare a 99233 and provided this note as documentation of the service.

Questions:

1. What level of E&M coding does this note qualify for? Select one of the following and explain why this level of coding is appropriate. 99231, 99232, 99233, 99234
2. What levels of history, examination, and medical decision making are included in the note?
3. What elements are missing in this note that would help qualify it for a higher level of coding and reimbursement? What suggestions would you make to the APN to expand her documentation to bill at a higher level?
4. Post on or before Day 3 a summary of your answers related to the case study selected.  Discuss the medicolegal implications for coding and how it would impact the role and responsibilities of the advanced practice nurse.
5. Read a selection of your colleagues’ responses.

Case Study 3 Medicolegal Considerations