Base Doctor's Notes and Medical Report

Chief Complaint Recorded by Dr. MOHAMED REDHA MOOSA YOOSUF AL LAWATI, Employee License No: 13921, on 05/03/2024 The patient, a 60-year-old female, visited Internal Medicine on 05/03/2024 for diabetes management Feels good, better diet control, exercises on and off Vitals: Weight: 81 kg BMI: 36 Blood Pressure: 123/89 Plan: Check bloods Continue treatment External Treatment Note Recorded by Dr. AYMAN AHMAD AL SAMRA, on 29/05/2022 Hypothyroidism, Hypertension, Type 2 Diabetes Mellitus, Dyslipidemia Social-Economic Assessment Recorded by Dr. AYMAN AHMAD AL SAMRA, on 29/05/2022 Patient never smokes, uses drugs, or drinks alcohol Lives with family Allergies Recorded by SOJIMOL V C, on 24/08/2021 No known allergies Vitals Recorded by SANTHI AMMINI THOMAS, on 05/03/2024 Tympanic Temperature: 36.3°C Heart Rate: 60 beats/min O2 Saturation: 98% Blood Pressure Sit: 123/89 mmHg Height: 148 cm Weight: 81 kg BMI: 37 Initial Diagnosis Recorded by Dr. MOHAMED REDHA MOOSA YOOSUF AL LAWATI, on 05/03/2024 E11.9 - Type 2 diabetes mellitus without complications (Primary) E78.5 - Hyperlipidemia, unspecified (Secondary) I10 - Essential (primary) hypertension (Secondary) E03.9 - Hypothyroidism, unspecified (Secondary) Plan of Care Lab Tests Recorded by Dr. MOHAMED REDHA MOOSA YOOSUF AL LAWATI, on 05/03/2024 CBC + Diff (Complete Blood Count with Differential) TSH (Thyroid Stimulating Hormone) Renal Profile Liver Function Profile Lipid Profile HbA1C (Glycated Hemoglobin) Fasting Glucose Medication Recommended/Advised Recorded by Dr. MOHAMED REDHA MOOSA YOOSUF AL LAWATI, on 05/03/2024 AMLO 5 MG, 1 tablet daily for 90 days CRESTOR 10 MG, 1 tablet daily for 30 days (evening) EXFORGE HCT 5/160/12.5 MG, 1 tablet daily for 90 days (morning) CONCOR AM 5 MG/5 MG, 1 tablet daily for 90 days (evening) DIAMICRON MR 60 MG, 1 tablet twice daily for 90 days XIGDUO XR 10 MG/1000 MG, 1 tablet daily for 90 days (morning) RYBELSUS 7 MG, 1 tablet daily for 90 days Surgery Recommended Recorded by Dr. AYMAN AHMAD AL SAMRA, on 29/05/2022 Coronary Angiogram + PCI Double Vessel

Claim Validation Report

Claim Details:

• Patient ID: 001
• Name: Anonymos for privacy
• Age: 60
• Gender: Female
• Date of Visit: 05/03/2024
• Chief Complaint: Diabetes management
• Insurance Policy Number: 123456789
• Practitioner's Name and Signature: Dr. MOHAMED REDHA MOOSA YOOSUF AL LAWATI

Validation Results:

Adherence to General Agreement:

• Adherence: Adheres
• Reason for Adherence: The claim submission follows the guidelines set by the General Agreement, including timely submission of claims, verification of the insured’s identity, and ensuring that covered services are medically necessary.

Adherence to Insurance Policy Coverage:

• Adherence: Adheres
• Reason for Adherence: The services provided, including outpatient consultations and prescribed medications, fall under the covered services as per the insurance policy, which includes outpatient treatments for chronic conditions like diabetes.

Doctor's Note and Medical Report Analysis:

• ICD-10 Codes: The doctor's note contained correct ICD-10 codes:
  • E11.9 - Type 2 diabetes mellitus without complications (Primary)
  • E78.5 - Hyperlipidemia, unspecified (Secondary)
  • I10 - Essential (primary) hypertension (Secondary)
  • E03.9 - Hypothyroidism, unspecified (Secondary)
• CPT Codes: No specific CPT codes were provided in the doctor's note. This is a discrepancy as the claim should include relevant CPT codes for the services rendered.
• Possible discrepancies:
  • Missing CPT codes for the outpatient visit and prescribed medications.
• Analysis: The doctor's note provides a comprehensive overview of the patient's condition and the treatment plan, including necessary lab tests and medications. However, the absence of CPT codes could lead to complications in the claim processing.

Claim Status Recommendation:

• Claim Status: Rejected
• Reason for Status: The claim is rejected due to missing CPT codes, which are essential for processing the claim accurately. The absence of these codes does not adhere to the requirements outlined in the General Agreement and the Insurance Policy Coverage.

General Recommendations:

• It is crucial for the attending physician to include all relevant CPT codes in the medical report to ensure that the claim can be processed without delays or rejections. The healthcare provider should also ensure that all documentation is complete and accurate before submission. Regular training on coding practices for medical staff may help reduce discrepancies in future claims. Additionally, the patient should be informed about the importance of having complete records for all future visits, including the necessity of pre-approval for certain treatments as outlined in the policy.

Amended Claim:

[Oman] Medical Insurance Claim Report