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Differential diagnosis in the analyzed clinical situation should first of all include benign breast formations, in particular, cysts (fibrocystic breast disease), galactocele (also called milk retention cysts), fibroadenoma, abscess and cystic form of carcinoma of this organ (Brkic et al., 2016). Unambiguously, taking into account the fact that just on medical history the patient had 2 pregnancies and more than 2 years of breastfeeding, and also taking into account the fact that after puncture of the formation, the latter disappeared and the clinicians received an opaque fluid, which indicates the cystic nature of this formation (Kumar & Prasad, 2019). The most likely causes are fibrocystic breast disease (the main causes are hormonal changes, which are especially symptomatic during periods of the menstrual cycle), as well as a retention cyst such as galactocele, which is formed as a result of a violation of the outflow of fluid through the milk ducts, more often during lactation.

Unambiguously, after medical practitioners receive the associated fluid from the lumen of the cystic formation, the latter should be subjected to cytological examination (screening) in order to possibly identify malignant atypical cells, or other cells in cellular elements that can give an important clue regarding the benignity of this tumor (Cottrell & Fisher, 2016). A biopsy of a breast mass is the most accurate method for excluding malignant growth in case of detecting suspicious signs in a cytological smear. In the case of confirmation of such a diagnosis as fibrocystic breast changes, the patient, in the absence of pain or other symptoms, does not need additional treatment, but at the same time, if breast cancer is suspected, psychological intervention or a neoadjuvant course of chemotherapy or radiation may be required. therapy, depending on the immune phenotypic characteristics of the tumor.

Given this burdened family history, the patient clearly has an increased risk of certain cancers, including breast cancer. Especially dangerous are the genetic forms of this disease, which are associated with mutations in the BRCA1 or 2 genes (Kumar & Prasad, 2019). But at the same time, in the case of adherence to the recommendations regarding screening (early detection of possible neoplasms using mammography and further biopsy), the patient will have a favorable prognosis for life.

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Coding and Billing Issues

Billing for nurse practitioner services is intricate and involves maneuvering through rules, policies, laws, and exceptions. Coding and billing errors have a significant impact on an organization’s bottom line. According to Oyeleye (2019), the billing and coding system in the United State is complex and practitioners are prone to make errors. Some of the errors can lead to disciplinary or legal actions. 

One of the issues is have encountered involves incident-to billing, especially when it involves billing an NP’s service under a physician’s NPI. Medicare rules allow “incident-to” billing in states that have a supervisory model of advanced practice registered nurses. Under this model, services provided by a supervised nurse practitioner can be billed under a physician’s NPI. Billing services as “incident-to” allows the services to be reimbursed at 100% of the Physician Fee Schedule rate. However, the rules of billing are complex. For instance, the physician is expected to have performed the initial service and subsequent services of a frequency that reflect their active participation in the management of the patient. Defining what constitutes “active participation” is challenging. For instance, a female patient was seen by a physician and treated for a recurrent urinary tract infection. After two weeks, the same patient returned to the clinic for follow-up, but upon the assessment and diagnostic tests, a new infection UTI was identified. A billing such as a client under “incident-to” was challenging because the physician had not participated in the management of the newly diagnosed condition. Another case involved a 57-year old woman visiting the clinic for her appointment. She had challenges managing her blood glucose and her adherence to medications was suboptimal. Her attending physician was not available. The challenge was to whether to bill the newly prescribed plan of care, which included metformin, under the physician NPI or NPs. I have also encountered issues billing and coding telehealth services, including incorrect use of modifiers. According to Barners et al., (2017), most of the billing errors and challenges facing nurse practitioners are related to state scope of practice and payment policies. Torren et al., (2020) identify payment policies as some of the significant barriers to APRN full practice in primary care.

One of the fundamental objectives of the Health Insurance Portability and Accountability Act was to simplify administrative processes. As a result, it led to the creation of a single identifier unique to every licensed health care provider that is used by all health insurers to facilitate billing. The Department of Health and Human Services and Center for Medicaid and Medicare Services (CMS) developed a system that assigns each provider a single number (National Provider Identifier, NPI), to help identify electronic transactions. The role of NPI is to uniquely identify providers in health care claims. NPIs are also used to track and identify providers prescription, in internal files to link proprietary provider identification numbers. The system covers all providers, including those working in hospitals. NPI is critical for nurse practitioners and advanced practice registered nurses who can bill patients. APRNs must apply for NPI to bill for their services. Once assigned, NPI is permanent and does not change based on practice settings or job. It is a 10-position numeric that does not contain specific information on the specialty or geographic location of the provider. APRNs must be aware of when to use their NPI to bill for services. This is may be influenced by geographic location of their practice, type of services and state scope of practice. It is critical for APRNs to update their knowledge of billing and coding systems because they keep on evolving.