reality check

Melissa Smith works at a multi-specialty health care provider’s office as a coder . She is highly productive and accurate with her work. It was a surprise to her when her office manager asked her to step into her office to discuss a patient complaint received regarding a patient billing dispute. It just so happened, Melissa coded this patient’s account. This claim was denied by the patient’s insurance company because it could not prove medical necessity. That is, the patient came in for shoulder pain, in which the provider promptly ordered a shoulder x-ray, but then the patient started having chest pain while waiting for the results of the shoulder x-ray. The provider quickly took vitals and ordered a chest x-ray and an EKG to rule out cardiac arrest. Fortunately, both the chest x-ray and EKG were negative. The patient, however, did not get this information regarding the chest x-ray added to his chart in a timely manner, so medical necessity had not been established when Melissa coded this patient’s record. The patient’s bill was submitted without the information on the chest pain. While Melissa’s manager was disappointed that Melissa didn’t catch this in time, she understood the reasoning behind the mistake.

How do you think the patient felt when he received a bill for a service that was not covered by his insurance?

How do you think Melissa felt for missing this important detail prior to the bill being submitted?

What should Melissa’s office manager do in order to ensure this does not happen again?

Please go into detail with your responses. Three to four paragraphs is appropriate.

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