Module 1 Revenue_Cycle_Workflow_Scenarios REVISED (1)

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Rasmussen College *

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2133

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Mechanical Engineering

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Feb 20, 2024

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HIM2133 Module 1 Revenue Cycle Workflow Scenarios Kierra Stinnette Note: A minimum of two (2) departments will be involved in the problem resolution for each scenario. See the assignment instruction for the key Revenue Cycle Departments/Team Players list. Available with the assignment instructions and under Lesson Content, are the corresponding roles and responsibilities for each department and team player. Scenario 1 During the process of preparing a claim for submission, an edit was encountered indicating there were surgical charges on the claim, but there are no ICD-10-PCS codes to correspond with any surgical services. Which Departments/Team Players would be involved in determining if the surgical services were performed for the patient and/or if additional codes need to be added to the account for billing? What is the role of each department/team player in remedying the situation? The coding department which is responsible for assigning codes to medical procedures and services. They would be reviewing the medical records of the patient to determine if additional codes need to be added to the account for billing. The role of the coding department would be to review the medical records of the patient to determine if additional codes need to be added to the account for billing. The billing department this department is responsible for submitting claims to insurance companies and processing payments for patients. They would be involved in ensuring that the claim is accurate and complete before submitting it to the insurance company. The billing department role would ensure that the claim is accurate and complete before submitting it to the insurance company. 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 reviewing the records, however, 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. The patient encounter may had the incorrect patient demographics attached in the MPI at the time of admission. Which Departments/Team Players would be involved in determining if the correct MPI demographics are attached to the patient’s records, retrieve/destroy the records that were submitted incorrectly, correct the MPI/records and follow-up with the patient to ensure they receive the correct information? What role does each department/team player in remedying the situation? Health Information Management: The HIM department is responsible for maintaining the integrity of the patient’s medical records. They would be responsible for verifying the accuracy of the patient's demographic information and ensuring that the correct information is attached to the patient's records. They would also be responsible for retrieving and destroying any records that were submitted incorrectly.

Patient Access Team: The patient access team is responsible for ensuring that patients receive the correct information about their medical records. They would be responsible following up with the patient to ensure that they receive the right information. Scenario 3 In November, a revenue cycle professional was attempting to code an ambulatory care visit when the professional noted a new CPT code is now available 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 that new CPT code. Which Departments/Team Players would be involved in reviewing the charge information and determining if the new CPT code is to be added to the charge code? What is the role of each department/team player in remedying the situation? Revenue Cycle Management: The RAM department is responsible for ensuring that the charge information entered for the patient’s date of service is accurate and complete. Their role consists of reviewing the charge information and determine if the new CPT code should be added to the charge code. Coding department: The coding department is responsible for assigning the appropriate CPT codes to the services provided to the patient. If the new CPT code is to be added, they would add it to the charge code as that’s their role. Scenario 4 The Hospital Administrator (CEO) received the end-of-month 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 including action steps, metrics for success with routine monitoring and reporting. Which Departments/Team Players would be involved in resolving the issue? What role does each department/team player have in remedying the situation? The Business Office: This department is responsible for reviewing the DNFB list of every account that did not bill and determining the cause. They also work collaboratively with the Medical Records department to ensure that all documentation is complete. The other department is the Physician’s: physicians are responsible for providing complete documentation, including final diagnosis, principal diagnosis, secondary diagnosis, procedures, documentation on the date of discharge, and timeliness. 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. Which Departments/Team Players would be involved in resolving the issue? What role does each department/team player have in remedying the situation?

Quality Assurance Department: This department is responsible for ensuring that the hospital is providing quality care to its patients. Nursing Department: This department is responsible for providing direct patient care. They would be involved in identifying any discrepancies in the patient’s care and providing the necessary documentation to resolve the issue. 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. She needs to be evaluated to determine if she meets the criteria for an extended stay prior to transfer. Which Departments/Team Players would be involved in the case review and length of stay determination? What role does each department/team player have in remedying the situation? Case Management Department: this department is responsible for coordinating the patient’s care and ensuring that she receives the appropriate level of care. They would be responsible for working in the admissions department to determine if the patient meets the criteria for an extended period to transfer to an SNF. Social Work Department: This department is responsible for providing social services to the patient and her family. They would be responsible for working with the patient and her family to ensure that they understand the situation and are comfortable with the care plan. 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. Which Departments/team players would be involved in resolving the issue? What role does each department/team player have in remedying the situation? The HIM Department is responsible for maintaining and managing the medical records of patients. They would be responsible for reviewing the patient’s medical record and ensuring that the MRI report is complete and accurate. Medical Records Department: this department is responsible for ensuring that the MRI report is complete and accurate and that the physician order for the MRI is included in the patient’s medical record.

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