Designed to enlighten and astonish   A patient can change their Medicare Advantage coverage outside of the normal enrollment calendar in “special situations.”  How many special situations does the government recognize? A. 2 B. 8 C. 12 D. 18 E. 20   The astonishing answer next week.       And now, last week’s answer     Your patient finds themselves in a Medicare Advantage plan she didn’t remember signing up for (also known as...

Designed to enlighten and astonish   Your patient finds themselves in a Medicare Advantage plan she didn’t remember signing up for (also known as “getting slammed”).  She likes her old plan. She comes to you for help.  Which one should you NOT do:     A. advise her to call her insurance company and ask them to undo the change. B. advise her to find a reputable agent, settle down into an “insurance home,” and...

Designed to enlighten and amaze.   Coding tools in the electronic health record are time-consuming to interpret and not always correct. Which of the following conditions are risk codes associated with an increase in capitation—and how would you find out?   A. Old MI B. Shortness of Breath C. Mild Intermittent Asthma D. Chronic anemia, not otherwise specified E. Low Back Pain     The astonishing answer next week.       Last week’s answer  ...

Designed to amuse and enlighten.     A patient you haven’t seen in over a year underwent a bone density test where an osteoporotic compression fracture was noted. Do you:     A. Submit the code for the pathologic vertebral fracture using an addendum to the test interpretation charge. B. Invite the patient to come in and discuss. C. Call the patient to inform her of the diagnosis and submit the code from that call....

Designed to enlighten and amaze   As you personally contact the patients on your panel who haven’t seen you yet for their yearly visit, you come across one who, though relatively healthy,  is particularly resistant to your entreaties. You should:   A. Threaten to kick them off your panel. B. Offer to do a home visit at no charge. C. Offer to pay them to come in. D. Tell them their co-pays are going to go...

Designed to enlighten and amaze!   You determine your patient has the clinical diagnosis of pneumonia and they improve with treatment but all testing, including x-ray and culture, are normal. Which statement is true? A. You can submit the pneumococcal pneumonia code based on your clinical impression. B. You can submit a “pneumonia, other specified organism” code. C. You can submit a “gram-negative pneumonia” code D You can submit a “lobar pneumonia, unspecified organism” code....

Designed to Enlighten and Amaze.   For Advanced Medicare Advantage providers only:   An elderly male patient with many active medical problems approaches you in July to see if you’d accept him as a new patient through your total-risk Medicare Advantage contract. He’s been on Medicare Advantage several years, but his past providers seem only interested in collecting data on him. He has had many hospitalizations in this past year. Should you accept him? A....

Designed to enlighten and amaze     You’re being audited for inappropriate coding. Which one of the following will result in a clawback? A. Atherosclerosis of the aorta addressed as the result of a chest xray B. Pathologic fracture of the vertebrate addressed as the result of a fracture assessment on a screening bone density. C. Pneumococcal pneumonia addressed based on a sputum culture. D. Opioid dependence addressed based on routine oxycodone that you prescribe....

Designed to Amaze and Enlighten   Can you diagnose ventricular fibrillation on the basis of a patient’s defibrillator interrogation?   The “shocking” answer below. x x x x x x x x x x x x x The answer: Yes. If the report indicates an episode of vfib took place and the patient was shocked, go ahead and submit the diagnosis at the time you see the patient and address the issue. Make it your...