Medicolegal consideration and role of advanced practice nurse essay

Medicolegal consideration and role of advanced practice nurse essay

Case study two presents a situation where the advanced practice nurse (APN) inserts a radial artery line while working in an intensive care unit. The line was placed on a patient who was in a hypertensive crisis and needed close monitoring of blood pressure while IV medications were given.Medicolegal consideration and role of advanced practice nurse essay. The International Classification of Diseases (ICD) codes are currently under the World Health Organization (WHO) and are used to classify diseases. Reimbursement for any provider services should follow appropriate documentation rules set up by the Center for Medicare and Medicaid Services and private insurance companies. Current Procedural Terminology (CPT) codes are used as an element for reimbursement along with proper documentation in the patient’s health record (Campo & Lafferty, 2016).
Correct Coding

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For the diagnosis of hypertensive crisis, the ICD-10 code used would be “I16”. For the placement of the radial artery line, the provider would use the CPT code “36620” (AAPC, 2018). Along with the correct coding, the APN would need to document in the patient’s chart about the acuity of the situation in which it was deemed necessary to place an arterial line for blood pressure management. Medicolegal consideration and role of advanced practice nurse essay.There seems to be some controversy regarding charges for the insertion of the line as well as coding for the usage of a “monitoring device” (a.k.a. the transducer/pressure equipment). However, it should be known the ICD code is used to establish the medical necessity for a CPT code (CDC, 2017).
Microlegal Implications and the APN
The APN must understand the legal responsibility of medical documentation and coding. All medical records are legal documents, so it is essential for the provider to be able to prove appropriate care was given to the patient. The care documented in the patient’s record should reflect the correct charges and proper procedures (Sullivan, 2012). In the possibility of legal suits against a provider, the medical record can be seen as a defensive tool to endorse the actions of the provider (Campo & Lafferty, 2016). Medicolegal consideration and role of advanced practice nurse essay.To prevent the provider from accidently committing fraud, documentation is key. Along with the need to reflect necessity for the care given, the APN should use the CMS guidelines for evaluation and management (E&M) when dictating in the patient chart. The E&M includes three main components: history, physical exam, and medical decision making (Campo & Lafferty, 2016). Comprehensive documentation and communication are essential to appropriate care and reimbursement.
References
American Academy of Professional Coders (AAPC). (2018). What is a CPT? Retrieved from
https://www.aapc.com/resources/medical-coding/cpt.aspx
Campo, T. M., & Lafferty, K. A. (2016). Essential procedures for emergency, urgent, and
primary care settings: A clinical companion (2nd ed.). New York, NY: Springer Publishing Company.
Centers for Disease Control and Prevention (CDC). (2017). International classification of
diseases, tenth revision, clinical modification (ICD-10-CM). Retrieved from http://www.cdc.gov/nchs/icd/icd10cm.htm
Sullivan, D. D. (2012). Guide to clinical documentation (2nd ed.). Philadelphia, PA: F.A. Davis
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