errors and legal issues

COMPETENCIES

737.4.4 Coding and Finance

The graduate evaluates the financial and legal impact of accurate billing and coding for pharmaceutical services in a healthcare system.

INTRODUCTION

Proper documentation is an important issue and area of concern to the health information management (HIM) professional. Quality of care, patient safety, and regulatory compliance are major focal points for all healthcare organizations. Health information management professionals serve as subject matter experts to ensure that clinical practices meet the requirements of external regulatory agencies as well as internal stakeholders. Health information management professionals can share their expertise by collecting and analyzing financial and clinical data that relate to the pharmacy department. The goal is for health information management professionals to be familiar with how pharmaceuticals impact reimbursement and with related standards surrounding pharmacy best practices.

SCENARIO

You are a clinical documentation improvement coordinator and a liaison to the HIM department. You are reviewing the record for a discharged patient that you received for review due to a rejected claim. You notice that there is documentation of medications administered to the patient in the progress note indicating blinatumomab infusion. However, the medication reconciliation section in the EHR states blood infusion. As you continue to look through the patient record, you confirm that blinatumomab is the correct infusion and note that the correct infusion is billable for $6,900 more than the blood infusion. You look through your database and find that this same error happened six other times this year. Since there is a pattern for blood infusion being coded and billed for blinatumomab infusion, you pull up the medication reconciliation section of the EHR and discover that there is a drop-down box for infusions, and the choices are alphabetized. Blinatumomab infusion comes right before blood infusion. You have brought this issue to the attention of your supervisor. Your supervisor has asked you to provide a report for senior management regarding the error, recommend a corrective action plan, and discuss further legal issues and responsibilities for HIM professionals.

REQUIREMENTS

A. Analyze the above scenario, and write a report for senior management discussing the financial, quality-of-care, and legal issues related to incorrect medication entry and incorrect billing by doing the following:

1. Discuss the financial impact on the hospital when errors like the one described in the scenario occur.

2. Discuss the quality-of-care and legal issues related to the data-entry error described in the scenario.

3. Recommend a corrective action plan to ensure that the error described in the scenario does not recur.

B. Explain the legal requirements for pharmaceutical reimbursement by doing the following:

1. Discuss the application of the National Drug Code (NDC) to the coding function.

2. Explain the steps an HIM professional should take to report suspected fraud and abuse in collected data.

3. Explain the importance of a pharmacy revenue cycle internal audit based on the scenario.

4. Discuss three important points that should be considered when conducting a pharmacy revenue cycle internal audit.

a. Justify why these points are important to consider.

C. Acknowledge sources, using APA-formatted in-text citations and references, for content that is quoted, paraphrased, or summarized.

D. Demonstrate professional communication in the content and presentation of your submission.

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