Wiki Ammending a Patients PHI

[AshleyMartin]

Brief synopsis of what transpired:

On our path to meaningful use, during the process of creating a problem list for a patient in our EHR, it was noticed that an incorrect diagnosis was submitted on a claim and processed for payment by the insurance company.

More specifically, a patient was evaluated in the clinic for chest pain and palpitations. Based on the patient's symptoms, a nuclear stress test was ordered and performed. The results were negative for CAD. The charge entry clerk submitted the claim with a diagnosis of CAD 414.01. There is no mention anywhere in the chart of the patient having CAD, the patient was never diagnosed with this. It was complete and fully data entry error on the part of the employee.

Problem is, now the patient is documented by her insurace company as having CAD.

What are the proper steps to follow to ammend the patient's claim so that she is not labeled as having CAD when she indeed does not?

 

[GaPeach77]

I had a case like this years ago, except the problem was found out when the parent received the EOB and the benign tumor had been coded as malignant, so you can imagine the horror this created. It has to be corrected because you are aware of it. Knowing this, the protocol to handle both situations is to send a letter of correction of the dx code to the insurance company along with any overpayment amount. I audit at a hospital and we are always refunding overpayments, while holding our breath that we do not get audited. Insurance companies are familiar with the overpayment from provider process and one RAC auditor mentioned to me that its the facilities that NEVER send an overpayment that we audit first.
Good Luck

Simone