As an advanced practice nurse (APN), it is essential to understand your medicolegal responsibilities as they relate to coding the services you provide to patients. Improper coding, undercoding, or overcoding can have serious implications for patients, providers, and the provider’s care setting. For this Discussion, you examine potential coding issues in case studies and consider the medicolegal responsibilities of the advanced practice nurse.
To prepare:
· Select one of the provided case studies.
· Review the patient documentation given for the case. Think about medicolegal considerations and the responsibilities of the advanced practice nurse.
· Consider the medical codes selected by the advanced practice nurse. Reflect on how the selections might impact clinical practice and billing. Think about how the impact might differ from primary to acute care settings.
By Day 3
Post a brief description of the patient documentation given for the case study you selected. Explain any medicolegal considerations, including the role and responsibilities of the advanced practice nurse. Then, explain how medical coding might impact clinical practice and billing, as well as how implications might differ from primary to acute care settings.
Case Study 1:
Sally Jones, an acute care advanced practice nurse, is making hospital rounds on the same patients her colleague nurse practitioner saw yesterday. Sally had five history and physicals to complete on admissions that came in overnight. At the beginning of her shift, she had to complete two emergency admissions and was then called to intensive care, where she spent most of the afternoon. She had to leave work early because of her husband’s retirement party. Because she knew most of the patients on her rounding list, she decided to visit each patient’s room quickly for about 10 minutes. She coded all of the visits the same way she had done the day before, with codes 99231 and 99232.
It is no secret that Evaluation and Management (E/M) miscoding and claims have been causing a major problems for the medical industry over the past several years. According to the Department of Health and Human services, there were about $6.7 billion inappropriately pain in 2010, that amounted to 21% of Medicare payments and a staggering 42% of incorrectly coded claims. Medical coding is the transformation of healthcare diagnosis, procedures, medical services and equipment into universal medical alphanumeric codes. The diagnoses and procedure codes are taken from medical record documentation, such as transcription of physician’s notes, laboratory, and radiologic results, etc. Subsequent hospital care CPT codes 99231 and 99232, respectively, require “a problem focused interval history” and “an expanded problem focused interval history. 99231 has a problem focused history, a problem focused exam and a straight forward MDM or Medical Decision Making (or of low complexity). 99231 requires documentation to support that the patient is stable, recovering, or improving. On the other hand, 99232 CPT code requires documentation to support that the patient is responding inadequately to therapy or has developed a minor complication. Such minor complications might include careful monitoring of co-morbid conditions requiring continuous active management (Centers for Medicare & Medicaid Services. (n.d.-a).
Description of Patient Documentation in Case Study 1
In the scenario, Sally Jones should have assessed and focused well on patient’s problem and history. Even though Sally knew the patients and saw them the other day, she should not coded all her patients the way she had done the day before. She did not see the patients for two days. The patients might have improved or not, might be recovered or developed minor complications. CPT codes 99231 and 99232 are totally different. If the exam is focused on history problem and the medical decision making is straight forward or low complexity, the code used is 99231. And if the exam is focused on expanded problem and the medical decision making is moderate complexity, then it coded as 99232 (Centers for Medicare & Medicaid Services. (n.d.-a).
Explain any medicolegal considerations, including the role and responsibilities of the advanced practice nurse.
Documentation is crucial to support the level of billing submitted for reimbursement and this documentation can include the systems reviewed, examinations performed, diagnoses made, treatment provided, and recommended follow-up. As advanced practical nurse practitioners, we have to ensure the codes are applied correctly during the medical billing process because it will reflect the claims sent to health insurance companies for reimbursement of services rendered by health provider (Sullivan, 2012). Sally Jones NP should know if the patient is improving and recovering, or not responding to treatments. What if the patient was not responding well to antibiotic and coded him with 99231. Inadequate response to treatment that support the levels of history and physical exam should be coded with 99232. I don’t think 10 minutes round for each patient is enough to evaluate and manage the patient appropriately. Typically, practitioners should have spent 25 minutes at the bedside or at the patient’s hospital unit. If the patient is unstable or has developed a new significant problem, practitioners should spend at least 35 minutes at the bedside for counselling and coordination of care with other physicians or other health care professionals. Time is a factor that indicates the extent of illness and this will guide us in selecting the correct CPT codes (Centers for Medicare & Medicaid Services, 2011).
Nurse practice laws and regulations are specific to each state. In the state of Texas, the state practice and licensure law restricts the ability of a nurse practitioner to engage in at least one element of NP practice. The state requires supervision, delegation, or team-management by an outside health disciplineor must work under physician supervision in order for the NP to provide patient care (American Association of Nurse Practitioners, 2014). In the case study #1, Sally Jones might face a criminal case of fraud because of miscoding or improper categorization of patient’s current condition. She coded all her patients with 99231 and 99232, which may not be appropriate for patient’s current condition. Also, miscoding or improper categorization of patient’s condition According to the Nursing Practice Act in Texas Board of Nursing, Sec. 301.452, a person is subject to denial of a license or to disciplinary action if there is a failure to care adequately for a patient or to conform to the minimum standards of acceptable nursing practice in a manner that, in the Board’s opinion, exposes a patient or other person unnecessarily to risk of harm. Also, if Sally Jones NP did not recognize the new problem or complication of her patient because she was in a hurry and coded the patient as 99231 (which is recovering) that subsequently lead to patient’s harm or death, then she is liable for her act. A nurse practitioner can be rightfully charged with negligence if his/her actions have caused harm to patients, and this should eventually lead to a malpractice lawsuit against the practitioner. The mission of the Texas Board of Nursing (BON) is to protect and promote the welfare of the people of Texas by ensuring that each person holding a license as a nurse in the State of Texas is competent to practice safely. The Board fulfills its mission through the regulation of the practice of nursing and the approval of nursing education programs (Texas Board of Nursing, 2013).
Then, explain how medical coding might impact clinical practice and billing, as well as how implications might differ from primary to acute care settings.
A Nurse Practitioner can bill for the level of care, time spent with the patient, diagnosis, preventative medicines, and patient counselling. Billing is complicated and requires education and resources to maximize reimbursement and avoid inappropriate billing practices. It is recommended that NP’s become knowledgeable of billing regulations, or work with the billing department to help guide their practice. The NP’s ability to demonstrate the clinical and financial outcomes related to the care they provide is critical to support changes in coverage and reimbursement rules to increase NP reimbursement and visibility (Centers for Medicare & Medicaid Services, 2011).
E/M miscoding is expensive for the entire medical industry. It is not only the Medicare paying out billions more than they should, but doctor’s offices and other medical facilities that are downcoding are losing out on revenue that they are legally entitled to as well. Improper coding such as upcoding impacts the long-term viability and solvency of the entire program, and burdens taxpayers and other parties within the medical industry unfairly. Downcoding on the other hand, could result in misallocated or loss of revenue, and the doctor’s office or medical facility suffers the consequences. By understanding how incorrect coding affects our practice, we can minimize our losses and prevent inaccurate claims to CMS. The acute care setting or in-patient medical coding follows different procedures than out-patient or primary care settings. Wherever medical services are performed, those services are translated into codes. Hospital coders often have a degree in Health Information Management which encompasses medical record technology and maintenance, as well as medical coding and billing. Due to the complexity of inpatient billing administration, inpatient hospital coders usually earn above the mean income of coders as compared to primary care settings (Centers for Disease Control and Prevention, 2014b).
American Association of Nurse Practitioners. (2014). State practice environment. Retrieved from
Centers for Disease Control and Prevention. (2014b). International classification of diseases, tenth revision, clinical modification (ICD-10-CM). Retrieved from
Centers for Medicare & Medicaid Services. (n.d.-a). ICD-10 code lookup. Retrieved June 8, 2016, from
Centers for Medicare & Medicaid Services. (2011). CMS Manual System Pub 100-04 Medicare ClaimsProcessing. Retrieved from
Texas Board of Nursing. (2013). Nursing Practice Act, Nursing Peer Review, & Nurse Licensure Compact Texas Occupations Code and Statutes Regulating the Practice of Nursing As Amended September 2013. Retrieved from

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