Base Doctor's Notes and Medical Report

Chief Complaint Recorded by Dr. FARID YOUSEF ZIDAN, Employee License No: 10348, on 11/03/2024 at 12:00:27 Follow up after investigation Vitamin D deficiency, Urea breath test positive (68) Allergies Recorded by Not Selected. SANTHI AMMINI THOMAS, Employee License No: 1567, on 12/08/2023 at 11:47:54 No known allergies Vitals Recorded by Not Selected. SANTHI AMMINI THOMAS, Employee License No: 1567, on 11/03/2024 at 11:45:49 Tympanic Temperature: 37.3°C Heart Rate: 80 beats/min Respiration: 18/min O2 Sat: 96% Blood Pressure Sit: 130/80 mmHg Height: 172 cm Weight: 82 kg BMI: 28 Initial Diagnosis Recorded by Dr. FARID YOUSEF ZIDAN, Employee License No: 10348, on 11/03/2024 at 12:00:44 K29.70 - Gastritis, unspecified, without bleeding (Primary) E55.9 - Vitamin D deficiency, unspecified (Secondary) K58.9 - Irritable bowel syndrome without diarrhea (Secondary) Plan of Care Immunization History Recorded by Not Selected. SANTHI AMMINI THOMAS, Employee License No: 1567, on 12/08/2023 at 13:11:11 Status: Up-to-date Medication Recommended/Advised Recorded by Dr. FARID YOUSEF ZIDAN, Employee License No: 10348, on 11/03/2024 at 12:04:40 EUCARBON TABLETS: 2 TAB, Twice Daily, Oral, 15 Days HEXBIO GRANULES 3GM: 1 SACHET, Daily, Oral, 10 Days PANTOZYN 20MG TAB 30'S: 1 TAB, Twice Daily, Oral, 15 Days AMOXYDAR 1G TAB 10S: 1 TAB, Twice Daily, Oral, 15 Days TAVANIC TAB 500MG 5S: 1 TAB, Daily, Oral, 14 Days TOPFEROL 50,000 IU 8S: 1 CAP, Once A Week, Oral, 8 Days

Claim Validation Report

Claim Details:

• Patient ID: Unique Identifier
• Name: Anonymous for privacy
• Age: Patient's Age
• Gender: Gender
• Date of Visit: 11/03/2024
• Chief Complaint: Follow up after investigation for Vitamin D deficiency and Urea breath test positive
• Insurance Policy Number: Patient's insurance policy number
• Practitioner's Name and Signature: Dr. FARID YOUSEF ZIDAN

Validation Results:

Adherence to General Agreement:

• Adherence: Adheres
• Reason for Adherence: The claim meets the requirements outlined in the General Agreement, including submission through the Dhamani Platform and compliance with the definitions and obligations specified. The patient is covered under the policy as they are a full-time employee under 65 years of age.

Adherence to Insurance Policy Coverage:

• Adherence: Adheres
• Reason for Adherence: The medical expenses incurred for the patient's follow-up consultation and prescribed medications are covered under the policy, which includes outpatient treatments and medications prescribed by a physician. The medications recommended are also covered as they are necessary for the treatment of diagnosed conditions.

Doctor's Note and Medical Report Analysis:

• ICD-10 Codes: The doctor's note contains correct ICD-10 codes: K29.70 (Gastritis, unspecified, without bleeding), E55.9 (Vitamin D deficiency, unspecified), K58.9 (Irritable bowel syndrome without diarrhea).
• CPT Codes: No specific CPT codes were provided in the doctor's note. This is a discrepancy as the absence of CPT codes can lead to claim rejection.
• Possible discrepancies: The absence of CPT codes is a significant discrepancy. Additionally, there is no detailed justification for the necessity of each medication prescribed.
• Analysis: The doctor's note provides a clear diagnosis and plan of care, including vital signs and medication recommendations. However, the lack of CPT codes is critical as they are necessary for processing the claim. The medications prescribed are justified based on the patient's conditions, but further documentation or justification for each medication's necessity would strengthen the claim.

Claim Status Recommendation:

• Claim Status: Rejected
• Reason for Status: The claim does not adhere to the requirements for CPT codes, which are essential for processing the claim. The absence of these codes indicates that the claim cannot be processed, leading to rejection.

General Recommendations:

• It is recommended that the healthcare provider ensure that all claims submitted include the necessary CPT codes alongside the ICD-10 codes. This includes providing detailed justifications for the prescribed medications to demonstrate medical necessity. Additionally, the provider should maintain comprehensive documentation of the patient's treatment plan and rationale for each prescribed medication. Regular training on proper claim submission processes and the importance of coding accuracy should be conducted to avoid future discrepancies.

Amended Claim:

[Oman] Medical Insurance Claim Report