Medical Insurance 7th Edition by Amy Blochowiak, Joanne Valerius, Nenna Bayes, Cynthia Newby

Exercise 9

Patient: Lakshmi Prasad
Medicare Nationwide sent the practice an RA on October 15, 2018. An extract from it, containing three procedures for Lakshmi Prasad, is shown in Figure 16.2.
Notice that of the three procedures listed, one has been denied.
FIGURE 16.2 Extract from Medicare Nationwide RA
1. What reason is given in the RA for the rejected procedure? What is the description of the procedure?
2. Refer back to the encounter form for Lakshmi Prasad in Claim Case Study 15.4 (page 491). Does the encounter form contain the same procedure code that is listed in the RA?
3. Refer next to Lakshmi Prasad's patient information form. Confirm that Lakshmi is an established patient. Also verify the reason for the visit as described on the patient information form.
4. Next, check the patient information form for Lakshmi's date of birth. Based on her age on the patient information form, what correction should be made to the encounter form and claim information?
5. Because the other two procedures in the claim have already been paid, use a blank CMS-1500 claim form to submit a new claim for the corrected procedure only. ( Note: Even if you created the original claim in Medisoft, you will need to submit the subsequent claim on a paper CMS-1500 form.)
6. How much do you think Medicare will pay for the corrected procedure? Note that Lakshmi has paid her $100 Medicare deductible for the year and that the plan pays for 80 percent of covered services (she has an Original Medicare plan).