What’s the difference between a claim rejection and a claim denial?

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H08 Medical Coding II Graded Project
Your project must be submitted as a Word document (.docx, .doc)*. Your project will be individually graded by your instructor and therefore will take up to a few weeks to grade.
Be sure that each of your files contains the following information:
Your name
Your student ID number
The course number and title (H08 Medical Coding II) Your email address
Be sure to keep a backup copy of any files you submit to the school!
PART 1 PART 2 PART 3
25 total points 45 total points 30 total points
5 points per answer 3 points per answer 3 points per answer
Part 1
1. List the four types of medical decision-making, and explain how the complexity of medical decision-making is determined.
2. What are the three types of wound repair, and what must be documented to code them?
3. Review the stages of chronic kidney disease (CKD) and end-stage renal disease (ESRD) in the guidelines of the ICD-10-CM manual. Explain the stages of CKD and when a code for ESRD may be assigned.
4. Explain the use of Anesthesia Qualifying Modifiers, and list and explain what add on codes are reported for qualifying circumstances.
5. A 10-year-old patient is admitted for multiple injuries after being hit by a car while riding his bike. Discuss the coding guidelines for reporting injuries.
Part 2
Evaluate the following chart information.
Patient presents for pilonidal cyst and skin tag removal. Patient has a history of hypertension and diabetes. Patient is taking lisinopril and metformin, and their chronic conditions are well managed.
PFSH
Occupation: Truck driver
Tobacco use: Stopped smoking in 2016 Alcohol: N/A
Seatbelt use: Yes Marital status: Married
Physical exam and procedure:
Patient is well developed, well-nourished, and in no acute distress. Patient was informed of the surgical risk factors, including postoperative bleeding, infection, and pain, and consented to the procedures. Patient has approximately 15 acrochordons to be removed from the abdomen and neck areas. Patient also has a pilonidal cyst approximately 4 cm in size. Due to the nature of the operation, the skin tags will be removed first. Patient was draped and the skin prepped in the usual fashion. Patient’s preference is electrocautery for the skin tags. Patient has 10 lesions for removal on the abdomen and 5 on the neck. Topical anesthesia was applied followed by lidocaine injections into each lesion. I gripped each lesion with forceps and then used the Bovie to cauterize the area. Patient tolerated the procedure well, and all lesions were successfully removed. Bacitracin and a sterile adhesive bandage were applied.
Next, I moved to the pilonidal cyst. Patient was rotated into a prone position and was draped and prepped in the usual fashion. 2% lidocaine was injected into the area around the cyst after local anesthetic. I used a #10 scalpel to incise the cyst. A large amount of white cystic matter was removed. I irrigated the wound copiously with saline solution. I then used the Bovie to remove the ventral margins around the cyst. The resulting wound was packed with Bacitracin and a sterile adhesive bandage was applied. Patient tolerated the procedure well, and blood loss was minimal.
1. What diagnoses should be listed on the patient’s claim?
2. What procedures should be listed on the patient’s claim?
3. Would a modifier be needed?
Answer questions 4–7 by referring to the CMS-1500 claim form in the figure below.

Click to enlarge image. (https://lessons.pennfoster.edu/pdf/42735202.pdf)
4. How many diagnosis codes can be reported on this claim?
5. In which box would the UCR for a procedure be listed?
6. After the claim is submitted electronically, what file format is used, and where does the claim go first?
7. In which box would you write the internal control number (ICN) when submitting a corrected claim?
8. What’s the difference between a claim rejection and a claim denial?
For questions 9–11, evaluate the electronic remittance advice in the figure below.
Click to enlarge image. (https://lessons.pennfoster.edu/pdf/42735203.pdf)
9. How much total payment will the provider receive for this claim?
10. How much is the patient responsible for? How much would the patient pay with 10% coinsurance?
11. Within the patient’s account, what will be the contractual adjustment?
For questions 12–15, evaluate the following ERA and the associated remark codes.
Click to enlarge image. (https://lessons.pennfoster.edu/pdf/42735204.pdf)

Click to enlarge image. (https://lessons.pennfoster.edu/pdf/42735205.pdf)
12. Why was part of this claim denied?
13. What should the medical biller/coder do to get this claim paid?
14. If the medical/biller coder thinks the insurance company has processed this claim incorrectly and needs to appeal the decision, how would they go about doing this?
15. Evaluate the remark codes. Are all codes properly assigned? Explain your answer.
Part 3
For questions 1–8, refer to the aged receivable report in the figure below.
Click to enlarge image. (https://lessons.pennfoster.edu/pdf/42735206.pdf)
1. Which patient has the oldest balance and may need to be sent to collections?
2. There was a clearinghouse issue that resulted in all the claims for one payer being rejected for a week. For which payer did the clearinghouse reject claims?
3. What insurance, having the highest balance, would it be most prudent to follow up with first?
4. If all claims are less than 14 months old, to which patient does the oldest claim and insurance belong?
5. Which patient likely received the same service on three dates in a row?

6. If the December 30 claim was filed on November 10 and the insurance company had a 90-day policy on filing a clean claim, what would the best
course of action be?
7. If both Octavia Butler and Arthur Clarke received the same service, what’s one way the provider could increase profits?
8. Kim Harrison has filed for Chapter 7 bankruptcy, and the provider receives notice that it has been listed as one of her creditors. What should happen to her account?
9. A patient receives a Level 3 office visit and an athletic training exam (CPT code 97169). Using the NCCI PTP edits in the figure below, give the proper modifier that would be used for reimbursement.
Click to enlarge image. (https://lessons.pennfoster.edu/pdf/42735207.pdf)
10. To catch patients before they leave for work, your supervisor instructs you to make collection calls on patient accounts at 7 am. Explain why this is
or is not appropriate.

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