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.
E. None of the above.
The shocking answer next week.
Last Week’s Answer:
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 for 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. Heck yes, what a great opportunity to work your skill while quickly generating outsized compensation.
B. Sure, it’ll take a couple of years but once I get his chronic illnesses under control, he’ll generate nice additional revenue to my pool.
C. Sure, it’ll cost you money, but that’s the cost of doing business.
D. No, can’t afford the cost—I’m trying to run a business for heaven’s sake.
E. Never. If I can’t make a buck, I don’t want anything to do with it.
F. How can I, the company I work for watches every dime.
The answer is A.
The practical reason:
The sicker the patient, the greater the potential compensation for your art and skill. Besides, chances are the patient is well into their stop-loss coverage and you can get him whipped into shape very cost effectively in the next six months (the stop-loss insurer will foot most of the bi and, because you did such a good job, reap the professional and financial benefits for years to come.
The moral reason:
it is flatly unethical to decline to accept a Medicare Advantage patient based on projected profit-loss. No discussion. If your organization puts you in this postion, leave. If you’re an orangization who puts this pressure on your clinicians, stop.
if you work for yourself and find financial considerations entering into your own decisions, get help—you are losing your way.