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Revenue Cycle Workflow Assignment

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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 would be involved in resolving the issue? What role does each department play in remedying the situation?

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. It is likely that the wrong patient demographics were attached to the patient encounter at the time of admission. Which Departments would be involved in resolving the issue? What role does each department play in remedying the situation?

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Scenario 3

In November, a revenue cycle professional was attempting to code an ambulatory care visit when the professional noted a new CPT code for the service provided. The charge information entered for the patient’s date of service does not contain a charge code with that new CPT code. Which Departments would be involved in resolving the issue? What role does each department play in remedying the situation?

Scenario 4

The Administrator received the end-of-month reports and noted that there is a significant increase in the Discharge, Not Final Billed (DNFB). The Administrator would like to have an update on the status of DNFB with an action plan for improvement. Which Departments would be involved in resolving the issue? What role does each department play in remedying the situation?

Scenario 5

Review of a patient’s record during a hospital stay reveals that the patient was admitted with a diagnosis of suspected sepsis. The 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 would be involved in resolving the issue? What role does each department play in remedying the situation?

Scenario 6

A Medicare patient was admitted to the hospital two days ago for treatment of a fractured hip. It was decided that surgical intervention was not appropriate. The patient is now being prepared to be transferred to a Skilled Nursing Facility (SNF) for rehabilitation; however; she has not met 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 would be involved in resolving the issue? What role does each department play in remedying the situation?

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, it is noted that the MRI results do not state a reason for the test and 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 would be involved in resolving the issue? What role does each department play in remedying the situation?