Lupus

Toni, Britina, Constance, LaShawn, Linda, &

Maria
What Is Lupus?
Lupus is a long-term autoimmune disease in which the body’s immune system becomes hyperactive
and attacks normal, healthy tissue. Symptoms include inflammation, swelling, and damage to the joints,
skin, kidneys, blood, heart, and lungs.

Due to its complex nature, people sometimes call lupus the “disease of 1,000 faces.”
In the United States, people report around 16,000 new cases of lupus each year, and up to 1.5 million
people may be living with the condition, according to the Lupus Foundation of America.
The Foundation say that lupus affects women in particular, and it is most likely to appear between the
ages of 15 and 44 years.

Lupus is not a contagious disease. A person cannot transmit it sexually or in any other way to another
person.
However, in rare cases, women with lupus may give birth to children who develop a form of lupus. This
is called neonatal lupus.
 Types Of Lupus
There are different kinds of lupus. We will focus mainly on systemic lupus erythematosus (SLE), but other
types include discoid, drug-induced, and neonatal lupus.

SLE is the most familiar type of lupus. It is a systemic condition. This means it has an impact throughout the
body. The symptoms can range from mild to severe.

It is more severe than other types of lupus, such as discoid lupus, because it can affect any of the body’s
organs or organ systems. It can cause inflammation in the skin, joints, lungs, kidneys, blood, heart, or a
combination of these.

This condition typically goes through cycles. At times of remission, the person will have no symptoms. During
a flare-up, the disease is active, and symptoms appear.
 Causes
Lupus is an autoimmune condition, but the exact cause is unclear.

What goes wrong?

The immune system protects the body and fights off antigens, such as viruses, bacteria, and germs.

It does this by producing proteins called antibodies. White blood cells, or B lymphocytes, produce these
antibodies.

When a person has an autoimmune condition, such as lupus, the immune system cannot differentiate between
unwanted substances, or antigens, and healthy tissue.

As a result, the immune system directs antibodies against both the healthy tissue and the antigens. This causes
swelling, pain, and tissue damage.

The most common type of autoantibody that develops in people with lupus is an antinuclear antibody (ANA).
The ANA reacts with parts of the cell’s nucleus, the command center of the cell.

These autoantibodies circulate in the blood, but some of the body’s cells have walls permeable enough to let
some autoantibodies through.

The autoantibodies can then attack the DNA in the nucleus of these cells. This is why lupus affects some organs
and not others.
 Kim Jones has been having issues with
tolerating her current medication she is
The Scenerio: on for the treatment of Lupus. She has
scheduled a follow up appointment
with her current Rheumatologist
Dr.Dania Masseoud.
 Patient
Demographics
Name: Kim Jones
DOB: 6/5/1987
Age:34
Address: 251 Meadowood Ridge
Lithonia Ga. 30038
Phone: 770 544-3334
Insurance: Cigna HMO
 Doctor
Demographics
Name: Dania Masseoud MD
Specialty: Rheumatologist
Office:Atlanta Rheumatology
Associates
Address:3193 Howell Mill Road, Suite
311 Atlanta, GA 30327
Phone: 404.997.7734
NPI #1568471258
Insurance Card
Benefits of Cigna Medical Plans:

● 24/7/365 live customer service, when and where employees need it.
● Digital tools for employees, including the myCigna mobile app
● Worldwide in-network coverage for emergencies.
● Most plans offer access to Cigna’s large national network of labs, x- ray and radiology offices,and dialysis centers
● Option for employers to bundle pharmacy, behavioral health, dental, and more
● Optional health and wellness incentive programs to encourage and reward employees
● Dedicated client service team
Cigna HMO

What is a HMO plan?

A Health Maintenance Organization (HMO) health plan offers a local network of doctor and hospitals for you to choose
from. Each HMO plan includes global emergency and urgent care coverage *24 hours a day, seven days a week.

If you choose a Cigna HMO plan it’s important to know the key feature of the plan:

● Primary care physician (PCP) selection is required. You can change your PCP at anytime.
● Referrals are required to see a specialist except OB/GYN no referral needed
● Out-of-network care is excluded with a Cigna HMO plan, unless it’s an emergency. Out-of-network care may be
covered for Cigna HMO Point of Service plan at a higher cost.
● Pre-certification may be required for hospitalizations and some types of outpatient care
● If you have a chronic health issue, you need to visit your PCP first. Your PCP may then refer you to an in network
specialist for care.
● If you get medical care outside of the plan network(such as a physician, hospital, clinic or pharmacy) those out-of-
network services will only be covered if the treatment is considered emergency or urgent care as defined by your
health plan document.
Soap Note
Pathology
Report
CMS Form
 Coding
E/M: 99214 - Office or other outpatient visit for the evaluation and management of an established
patient, which requires at least 2 of these 3 key components:

● A detailed history;
● A detailed examination;
● Medical decision making of moderate complexity

ICD-10-CM: M35.9 - Systemic lupus erythematosus, unspecified.

R76.8: Other specified abnormal immunological findings in serum.

Claims Processing
 Cycle of Claims Processing

● The cycle of claims processing starts when a health insurance claim form is submitted by the
provider (electronically or paper form) and until the claim is paid or denied by the insurance carrier.
● There are four steps in the process of insurance claims: submission, processing, adjudication, and
payment/denial.
● Processing is completed by the payer by collecting information about the patient, provider, and the
services received provided on the claim form.
● Adjudication is when services and information reported on claim form is compared to patients
health benefits to ensure all information needed is available, claim hasn’t been paid previously,
payer rules were followed, and services billed are covered benefits for patient.
● If a claim is denied, an EOB (Explanation of Benefits) is sent by the provider to the patient to pay
for any unpaid services that the insurance carrier did not pay.
https://www.medicalnewstoday.com/articles/323653

https://www.atlantarheumatology.com/

https://www.nextgen.com/blog/2016/january/healthcare-claims-processing-and-its-impact-on-healthcare-cos
ts

http://blogs.imms.com/healthinsurance/2011/04/what-is-the-life-cycle-of-insurance-claim-form/