Real-Life Decision Making -- Solution
You code the surgical procedure and carry on.
You assume the procedure was justified and carry on with your work. After all, you can't waste your time looking extensively into every record and procedure.
A few months later, another medical record from the same doctor comes in. This time, you are certain that the procedure listed in the records was not called for or performed. You decide to investigate. You find that the claim is fraudulent.
It makes you wonder if you should have checked into the gallbladder case after all.
"If you're reviewing a record and see something that you don't think quite fits with this type of surgery, you need to check it out," says Shirley Davis. She is a professor of health information management and medical coding.
"You need to look in the nurse's notes and in the surgical notes," she says. "If you find something doesn't match, you have to look further to make sure the doctor didn't add something on that never occurred."