you work for a third party payer performning medical records review. your job is to match codes that were submitted on the claim to documentation in the medical record. you notice that a code has been input for a colonoscopy procedure, but you don't see the procedure report anywhere in the record. as the third party payer representative what will your action be regarding the code that was submitted on the claim form?

As a third-party payer representative, your primary responsibility is to ensure accurate billing and determine whether the codes submitted on the claim form match the documentation in the medical record. In this case, where you do not find the procedure report for the colonoscopy in the medical record, you would need to take appropriate action. Here's how you can proceed:

1. Assess the claim documentation: Carefully review the claim form and any supporting documentation to confirm the code that was submitted for the colonoscopy procedure.

2. Determine potential issues: Consider possible reasons for not finding the procedure report in the medical record. It could be an administrative error, missing or misplaced documents, or an oversight during the claims submission process.

3. Conduct further investigation: Request additional information from the healthcare provider or facility that submitted the claim. Contact them by phone or email, asking for clarification or requesting the missing procedure report.

4. Collaborate with the healthcare provider: Engage in a dialogue with the healthcare provider's billing or medical records department to address the discrepancy. Inform them about the missing procedure report and request their assistance in resolving the issue.

5. Document the process: Maintain detailed records of your investigation, including any communication with the healthcare provider or facility. This documentation is essential for tracking the progress of the resolution and maintaining a comprehensive audit trail.

6. Utilize coding guidelines: Consult relevant coding guidelines to determine if an alternative coding option is appropriate based on the available documentation, or if any coding rules or requirements have been violated.

7. Take appropriate action: Depending on the outcome of your investigation and collaboration, you may need to make a decision regarding the code submitted on the claim form. This could involve denying the claim, requesting further documentation, or taking any other necessary steps as guided by your organization's policies and procedures.

Remember, your objective is to ensure accurate coding and billing practices. If the missing procedure report is confirmed by your investigation, it is crucial to address the issue promptly and follow the proper protocols to rectify any discrepancies or errors.