NURS 6550 Medicolegal Considerations Week 1 Discussion

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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.

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 of the advanced practice nurse.

Case Study 1

The APN working in urgent care sees a patient with a right ankle sprain. What ICD-10 code would be appropriate for this patient encounter? What additional information and documentation is needed for a correct ICD-10 to be identified?

Case Study 2

The APN inserts a radial arterial line in an ICU patient with a hypertensive crisis. What ICD-10 and CPT code would be appropriate for this procedure? Identify any additional information and documentation that is needed for correct coding.

Case Study 3

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?

Case Study 4

Lisa Smith, an acute care advanced practice nurse, is making hospital rounds on the same patients her colleague nurse practitioner saw yesterday. It took her 50 minutes to see 10 of her patients and 30 minutes to see each of the remaining patients on her list. She used the same code for all visits—99233.

Questions:

  1. Is the AG-ACNP’s use of the same billing code (99233) appropriate for all of the patient’s seen based on the amount of time spent with each patient?
  2. What level of documentation must be included in each note to support this code?
  3. How does the selection of this one code impact clinical practice and billing?

To prepare:

  • Select one of the provided case studies. (Note- your instructor may assign the case to be completed)
  • Review the information provided and prepare answers to the questions posed in the case study.

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.

Read a selection of your colleagues’ responses.

Respond on or before Day 6 to at least two of your colleagues on two different days who selected a different case study than you. Share additional insights or alternative perspectives.

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