Patient Complaints and Evaluations
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Patient Complaints and Evaluations

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Questions and Answers

What does the fifth digit of the ICD-10 code H35.3131 specify?

  • Type of patient
  • Severity (correct)
  • Laterality
  • Body system

    • What defines a patient as an established patient in the context of ophthalmological services?

  • If they were last seen more than three years ago.
  • If they were seen by any doctor in the same practice within the last three years. (correct)
  • If they were last seen within the last two years.
  • If they have never been seen by the practice before.

    • What is the primary purpose of coding using ICD-10 codes?

  • To track patient demographics
  • To provide patient education
  • To bill claims to insurers (correct)
  • To inform treatment plans

    • Which of the following is the correct code for an intermediate examination of a new patient?

    <p>92002</p> Signup and view all the answers

    Which of the following correctly describes bilateral laterality in ICD-10?

    <p>3 for bilateral eye</p> Signup and view all the answers

    What happens if a patient was seen for a minor complaint less than three years ago?

    <p>They remain an established patient.</p> Signup and view all the answers

    What is crucial for providing medical services and securing payment?

    <p>Medical necessity</p> Signup and view all the answers

    For billing purposes, if a patient was seen by a different doctor within the same practice two years ago, how are they classified?

    <p>Established patient</p> Signup and view all the answers

    If a patient returns after four years for a comprehensive exam, how are they classified?

    <p>New patient</p> Signup and view all the answers

    Which code would appropriately support the need for retinal photos?

    <p>H4O.013</p> Signup and view all the answers

    What do S codes provide in the context of eye exams?

    <p>Routine eye exams without medical necessity</p> Signup and view all the answers

    Which code is used for comprehensive examination and evaluation of an established patient?

    <p>92014</p> Signup and view all the answers

    Which of the following statements about S codes is NOT true?

    <p>They are CPT codes.</p> Signup and view all the answers

    How does the Medical Decision Making (MDM) for a 63-year-old patient with cataracts differ from that of a 21-year-old myope?

    <p>It requires more complex decision-making for older patients.</p> Signup and view all the answers

    What do S codes allow doctors to do with regard to billing for routine eye exams?

    <p>They allow setting fees at different levels than complex codes.</p> Signup and view all the answers

    Which condition would support the code for dilation of lacrimal punctum (68801)?

    <p>H0.213 (epiphora due to excess lacrimation)</p> Signup and view all the answers

    What should be done when entering new or changed information after the original date of service?

    <p>Identify it as an amendment, sign and date it.</p> Signup and view all the answers

    What is the correct method for amending a paper medical record?

    <p>Strike through the original content with a single line and sign the revision.</p> Signup and view all the answers

    How should original content in a record be treated when an amendment is made?

    <p>It must be clearly identified and not deleted.</p> Signup and view all the answers

    What is necessary to do when co-directing a paper medical record?

    <p>A single line should be struck through the original content.</p> Signup and view all the answers

    What does CMS encourage regarding the documentation of entries during a service?

    <p>Providers should enter all relevant documents at the time of service.</p> Signup and view all the answers

    What should electronic records provide when modifications are made?

    <p>A reliable means to clearly identify original and modified content.</p> Signup and view all the answers

    What action is discouraged when making corrections or addenda to a medical record?

    <p>Deleting original entries.</p> Signup and view all the answers

    What should a provider primarily focus on during a patient examination?

    <p>The actual condition the patient is experiencing</p> Signup and view all the answers

    What is the purpose of the Narrative of Present Illness (NPI)?

    <p>To document the chronological development of the patient's present illness</p> Signup and view all the answers

    Which of the following is NOT a component of the NPI checklist?

    <p>Patient age</p> Signup and view all the answers

    What should be documented about the duration of the problem according to the NPI checklist?

    <p>How long the problem has been a concern</p> Signup and view all the answers

    Why might a patient express a need for new glasses?

    <p>To express reduced visual acuity</p> Signup and view all the answers

    Which factor can influence the symptoms experienced by the patient?

    <p>Modifying factors such as heat or artificial tears</p> Signup and view all the answers

    In the context of patient evaluations, what does 'context' refer to?

    <p>Any activities associated with the issue</p> Signup and view all the answers

    Which statement best describes the chief complaint in a patient assessment?

    <p>The primary symptom that the patient is experiencing</p> Signup and view all the answers

    What is a primary benefit of submitting claims through a clearinghouse?

    <p>They check for coding errors before submission.</p> Signup and view all the answers

    Which method of claim submission is typically the least efficient?

    <p>Manual submission via fax or mail.</p> Signup and view all the answers

    Why might an office choose to submit claims through a clearinghouse?

    <p>To use a centralized system for claim rejections or denials.</p> Signup and view all the answers

    What type of information is NOT typically required when submitting a claim?

    <p>Detailed treatment history of the patient.</p> Signup and view all the answers

    In what situation would a provider likely submit claims manually?

    <p>When the insurer does not use a direct portal or clearinghouse.</p> Signup and view all the answers

    Which statement accurately describes Availity?

    <p>An online provider portal used by multiple insurers.</p> Signup and view all the answers

    What is essential to have before submitting a claim?

    <p>The patient's demographic data and insurance details.</p> Signup and view all the answers

    What is one of the key benefits of submitting claims through a clearinghouse?

    <p>They check claims for coding errors before submission.</p> Signup and view all the answers

    Which scenario typically necessitates manual claim submission?

    <p>The insurer does not utilize Availity and lacks a direct portal.</p> Signup and view all the answers

    What demographic data is necessary to submit a claim?

    <p>Patient’s demographic data and insurance details.</p> Signup and view all the answers

    How does using a direct provider portal for claims submission benefit healthcare providers?

    <p>It provides eligibility information right before submission.</p> Signup and view all the answers

    What information is typically NOT needed during claim submission?

    <p>Details of the medical facility’s internal policies.</p> Signup and view all the answers

    Why is scanning or copying the patient's insurance card important before submitting a claim?

    <p>It ensures access to the policy and contact information of the insurer.</p> Signup and view all the answers

    Study Notes

    Patient Perception and Complaints

    • Chief complaints like "trouble walking" or "leg pain" need thorough evaluation beyond patient perception.
    • Patient's belief that new glasses will solve vision issues indicates underlying conditions like myopia or AMD.
    • Focus on the actual symptoms (e.g., blurred vision or headaches) rather than patient assumptions.

    Narrative of Present Illness (NPI)

    • NPI is a chronological account of the patient's illness from initial symptoms to current status, guiding treatment decisions.
    • Documentation can be done by both doctors and technicians.
    • Important NPI Checklist components:
      • Location of the problem (unilateral or bilateral eyes).
      • Duration of the issue.
      • Contextual factors (associated activities).
      • Modifying factors (conditions that alleviate or worsen symptoms).
      • Quality of the problem nature.

    Amending Medical Records

    • CMS recommends documenting all relevant entries at the time of service; amendments should clearly indicate changes made post-visit.
    • Original entries must remain intact, marked with a single strike through in paper records and tracked in electronic records.
    • Correctly document the date and author of amendments.

    ICD-10 Coding and Diagnosis

    • Use specific ICD-10 codes for accurate billing purposes; organized by body system, laterality, and severity.
    • Example ICD-10 Codes:
      • H52.223 for bilateral regular astigmatism.
      • H35.3131 for early dry stage, nonexudative age-related macular degeneration.
    • Importance of avoiding unspecified laterality codes for clarity.

    Types of Patients in Billing

    • New Patients: Never seen in the practice or not seen for over three years.
    • Established Patients: Seen by any practitioner in the practice within the last three years.

    Ophthalmological Exam Codes

    • Primary codes for ophthalmological exams include:
      • 92002: Intermediate medical examination for new patients.
      • 92004: Comprehensive examination for new patients.
      • 92012: Intermediate examination for established patients.
      • 92014: Comprehensive examination for established patients.

    Medical Necessity in Documentation

    • Document services with clear medical necessity for payment approval.
    • Ensure test justifications align with documented diagnoses to avoid billing issues.

    S-Codes for Routine Exams

    • S-Codes enable billing for routine eye exams with lower complexity, used when medical necessity is not established.
    • Provide a structured alternative for routine wellness care, differing from more complex codes.
    • Ensure compliance with state standard care guidelines despite confusions with similar procedures for varying patient needs.

    Claims Submission Process

    • Collect patient's demographic data and insurance details from intake paperwork.
    • Copy or scan the front and back of the insurance card for policy and contact information.
    • Consider scanning or copying IDs of patients or their legal guardians for verification.

    Submission Methods

    • Directly through Insurer Portals:

      • Utilize online provider portals for submitting claims, which is the fastest method.
      • Access eligibility information before submission to ensure accurate claims.
      • Example: Availity.com serves as a third-party portal for many insurers.

    • Indirectly through Clearinghouses:

      • Use if insurers lack a straightforward portal or if their portal is complex.
      • Clearinghouses act as intermediaries between the office and insurance companies.
      • Benefits include:
        • Claim scrubbing to check for coding errors.
        • Batched submission of prepared claims.
        • Electronic information exchange with insurers.
        • Management of claim rejections or denials.

    • Manual Submission:

      • Offered as an option only when no direct portal or clearinghouse is available.
      • Requires filling out a claim form and submitting it via fax or postal mail.
      • This method is less efficient, likened to outdated practices.

    Claims Submission Process

    • Collect patient's demographic data and insurance details from intake paperwork.
    • Copy or scan the front and back of the insurance card for policy and contact information.
    • Consider scanning or copying IDs of patients or their legal guardians for verification.

    Submission Methods

    • Directly through Insurer Portals:

      • Utilize online provider portals for submitting claims, which is the fastest method.
      • Access eligibility information before submission to ensure accurate claims.
      • Example: Availity.com serves as a third-party portal for many insurers.

    • Indirectly through Clearinghouses:

      • Use if insurers lack a straightforward portal or if their portal is complex.
      • Clearinghouses act as intermediaries between the office and insurance companies.
      • Benefits include:
        • Claim scrubbing to check for coding errors.
        • Batched submission of prepared claims.
        • Electronic information exchange with insurers.
        • Management of claim rejections or denials.

    • Manual Submission:

      • Offered as an option only when no direct portal or clearinghouse is available.
      • Requires filling out a claim form and submitting it via fax or postal mail.
      • This method is less efficient, likened to outdated practices.

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    Related Documents

    Coding and Billing PDF
    Claim Submissions PDF
    Claim Submissions PDF

    Description

    This quiz focuses on analyzing patient complaints, specifically their perceived solutions to chief complaints such as trouble walking or visual issues. Understanding the actual experiences behind these complaints is crucial for effective evaluation and diagnosis. Explore how to accurately interpret patient statements in a clinical context.

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