Topic: Health Information Document Management
Case Study 1 - Using the Internet to Expedite Patient Care
Shon Brown, a 35-year-old male, arrives at his primary physician with complaints of a "cough and shortness of breath that will not go away." He states that he has had a bark-like cough, pain in extremities, and fever for at least four days and feels like his symptoms are worsening rather than subsiding. When asked, he states that he did not take the flu shot this year. After a routine physical examination, Dr. Williams orders a CBC, chest X-ray, and CT of the chest, with and without contrast, and gives him a prescription for a cough suppressant and antibiotics. Dr. Williams will be in touch with him after the lab work and diagnostic procedure findings are in:
1. Shon's lab and diagnostic findings are indicating pneumonia. You are to create a letter to him, per Dr. Williams, stating his findings are positive for pneumonia (acute pathology) and he should contact the office for a flu shot when he feels better.
2. You have a consent to use E-mail communication on file for Shon. Write an e-mail to him about his lab and diagnostic test results, requesting he contact the office by telephone or internet to arrange an appointment to receive a flu shot.
After reading the required chapter on Using the Internet to Expedite Patient Care, complete and submit the following in an APA format:
- Begin your case study with an introduction explaining the purpose of the case study.
- In no more than two paragraphs explain what a Public Health Record is, what is comprised of, and who (patient, agency, committee, etc.) regulates entry to the PHR?
- Write an e-mail to Shon about his lab and diagnostic test results, requesting he contact the office by telephone or internet to arrange an appointment to receive a flu shot.
- Important reminder - do not forget to include a reference page, including all sources cited in your essay.
Format your Case Study using APA style. Use your own words, and include citations and references as needed.
Case Study 2 - EHR Coding and Reimbursement
A 16-year-old female who has asthma has an Emergency Department visit for angina, shortness of breath, and wheezing. The doctor performs a chest x-ray, breathing treatments, and a Nuclear Medicine Stress Test utilizing a treadmill while monitoring the patient's heart palpitations. While the patient is in the ED, the doctor evaluates her asthma and changes her prescription medication.
Review the chapter and consider the following questions:
1. How would you select the ICD-9 and CPT codes for the procedural claim (encounter) for the ED visit?
2. What diagnosis and procedure codes will result in full reimbursement for the procedures rendered?
3. How will the claim demonstrate the medical necessity for the exams?
After reading the required chapter on EHR Coding and Reimbursement complete and submit the following in an APA format:
- Begin your case study with an introduction explaining the purpose of the case study.
- In no more than three paragraphs explain and answer the questions listed above. Be descriptive on the steps necessary to perform the above scenario. Defend your response and use terminology related to the scenario.
- Describe billing upcoding and downcoding. Describe the penalties related to performing these tasks. Is there a chance for the scenario listed above to be upcoded or downcoded? Explain your response.
- Important reminder, do not forget to include a reference page, including all sources cited in your essay.
Format your Case Study using APA style. Use your own words, and include citations and references as needed.