Nova Southeastern University Medical Decision Making Discussion

Description

Diagnosis	Urinary Tract Infection (UTI)
ICD-10 code for the diagnosis	N39. 0 (Urinary Tract Infection, Unspecified)
CPT code for the diagnosis.	Urinalysis- 81001 Urine Culture- 87086
HPI elements to capture the CPT code.	Brief
# of ROS elements to capture the CPT code.	Gastrointestinal and Genitourinary (Problem Related)
# of PE elements to capture the CPT Code.	6 or more elements (expanded problem focused)
Determine the Plan and follow up care necessary to meet the level of Medical Decision Making (MDM)	Plan is to prescribe oral antibiotic to treat infection Follow up if symptoms do not resolve after entire course of antibiotic treatment and another UA Low Complexity

Develop a short paragraph about the article and how it relates to Quality Improvement with billing and coding

Healthcare is constantly expanding, which is leading to more nurse practitioners in the outpatient setting with more autonomy with diagnosing. It is important that outpatient providers are educated on coding and informed of the ways to be reimbursed at the highest rate for the care they provide to their patients. Olmstead (2018) states that the implementation of coding for diagnosing has impacted reimbursement for NPs and providers need to understand the guidelines for accurate documentation and billing. Having ICD codes available for health care providers not only helps capture the patients state of illness but it also serves as a guide for other specialists and insurance payers leading to quality improvement practices. A key point to take away from the article is that clinicians should evaluate their )agnosing frequency report and review denial data to assess for missed opportunities and educational moments(Olmstead, 2018, p. 10).

References

Olmstead, J. (2018). Coding & billing practices. Understanding the importance of diagnosis coding. Nurse Practitioner, 43(10), 8p. https://doi.org/10.1097/01.NPR.0000544998.00017.de

World Health Organization. (n.d.). World Health Organization. Retrieved January 10, 2023, from https://icd.who.int/browse10/2019/en#/N39.0

Explanation & Answer:

150 words

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