In this discussion, we will explore all three coding systems

Discussion: Medicolegal Considerations As an advanced practice nurse (APN), you will be responsible for identifying the ICD-10 diagnosis code, CPT code for procedures, and the E&M code for billing of services. Most nurses have not been involved in the coding of diagnoses or procedures, so these systems are probably unfamiliar to you. In this discussion, we will explore all three coding systems. International Classification of Disease, 10th Edition, (ICD-10) is the system used to identify the diagnosis for the patient. The system is very specific and selecting the correct code can facilitate the approval of procedures as well as correct billing of services. Current Procedural Terminology (CPT) are codes that identify procedures that have been completed or tests that are requested. Most CPT codes are related to what is considered appropriate ICD-10 codes. For instance, you would not code a bronchoscopy 0BJ08ZZ and relate it to a diagnosis code of low back pain M54.5. The reimbursement would probably be denied because the diagnosis and procedure do not correlate. Evaluation and management (E&M) codes are used to determine the complexity of services provided to the patient. Specific documentation must be included in the patient visit note to support the E&M code billed. Improper coding, undercoding, or overcoding can have serious implications for patients, providers, and the provider’s care setting. For this Discussion, you will examine potential coding issues in case studies and consider the medicolegal responsibilities of the advanced practice nurse. Case Study 4 Lisa Smith, an acute care advanced practice nurse, is making hospital rounds on the same patients her colleague nurse practitioner saw yesterday. It took her 50 minutes to see 10 of her patients and 30 minutes to see each of the remaining patients on her list. She used the same code for all visits—99233. Questions: Is the AG-ACNP’s use of the same billing code (99233) appropriate for all of the patient’s seen based on the amount of time spent with each patient? What level of documentation must be included in each note to support this code? How does the selection of this one code impact clinical practice and billing? To prepare: Select one of the provided case studies. (Note- your instructor may assign the case to be completed) Review the information provided and prepare answers to the questions posed in the case study. Post on or before Day 3 a summary of your answers related to the case study selected. Discuss the medicolegal implications for coding and how it would impact the role and responsibilities of the advanced practice nurse.

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