Base Doctor's Notes and Medical Report

Chief Complaint Recorded by Dr. ZAID SAHEB MOHAMMED SEDAAI, Employee License No: 10371, on 05/03/2024 at 09:29:00 Smoker, non-alcoholic Chief Complaints: General tiredness, body aches, poor sleep, change in appetite, mild weight gain History of Present Illness: Symptoms started 1 year ago after marriage Past Medical History: Cholelithiasis Past Surgical History: None Relevant Family History: Father: Colon cancer Brother: Hypothyroidism Mother: Diabetes Mellitus (DM), Hypertension (HTN) Current Medications: None Known Allergies: None Physical Examinations: Looks healthy Normal heart and chest Normal abdomen Impression / Diagnosis: Hypothyroidism Vitals Recorded by Not Selected. SANTHI AMMINI THOMAS, Employee License No: 1567, on 05/03/2024 at 09:04:34 Tympanic Temperature: 36.2°C Heart Rate: 79 beats/min O2 Sat: 100% Blood Pressure Sit: 135/84 mmHg Height: 181 cm Weight: 99 kg BMI: 30 Initial Diagnosis Recorded by Dr. ZAID SAHEB MOHAMMED SEDAAI, on 05/03/2024 at 09:29:10 E03.9 - Hypothyroidism, unspecified (Primary) Plan of Care Lab Tests Recorded by Dr. ZAID SAHEB MOHAMMED SEDAAI, on 05/03/2024 at 09:34:06 Vitamin B12 ESR (Erythrocyte Sedimentation Rate) CBC + Diff (Complete Blood Count with Differential) TSH (Thyroid Stimulating Hormone) Liver function profile Lipid profile Glucose, fasting Vitamin D, 25-Hydroxy Medication Recommended/Advised Recorded by Dr. ZAID SAHEB MOHAMMED SEDAAI, on 06/03/2024 at 13:24:58 Songha Night Tablets, Dosage: 2 TAB Daily, Oral, for 30 Days Centrum Men Tablets, Dosage: 1 TAB Daily, Oral, for 30 Days Fluzyn 20mg Caps, Dosage: 1 CAP Daily, Oral, for 30 Days

Claim Validation Report

Claim Details:

• Patient ID: Unique Identifier
• Name: Anonymos for privacy
• Age: Patient's Age
• Gender: Gender
• Date of Visit: 05/03/2024
• Chief Complaint: General tiredness, body aches, poor sleep, change in appetite, mild weight gain
• Insurance Policy Number: Patient's insurance policy number
• Practitioner's Name and Signature: Dr. ZAID SAHEB MOHAMMED SEDAAI

Validation Results:

Adherence to General Agreement:

• Adherence: Adheres
• Reason for Adherence: The claim follows the stipulated guidelines of the General Agreement, including the submission of valid claims through the Dhamani Platform, and the services provided fall under the covered services as defined in the policy.

Adherence to Insurance Policy Coverage:

• Adherence: Adheres
• Reason for Adherence: The medical services provided are within the scope of the insurance policy coverage, including outpatient consultations and necessary laboratory tests for the diagnosed condition of hypothyroidism.

Doctor's Note and Medical Report Analysis:

• ICD-10 Codes: The doctor's note contains the correct ICD-10 code: E03.9 - Hypothyroidism, unspecified (Primary).
• CPT Codes: No specific CPT codes were provided in the doctor's note. This is a discrepancy as CPT codes are necessary for billing purposes.
• Possible discrepancies: Lack of CPT codes in the medical report, which may lead to claim rejection. All other information appears to be complete and accurate.
• Analysis: The doctor’s note provides a clear diagnosis of hypothyroidism with relevant medical history and current medications. However, the absence of CPT codes for the consultations and lab tests is a significant oversight, as these codes are essential for processing the claim accurately.

Claim Status Recommendation:

• Claim Status: Rejected
• Reason for Status: The claim does not adhere to the requirements due to the absence of correct CPT codes, which are necessary for the processing of medical claims. Without these codes, the claim cannot be accurately assessed for payment.

General Recommendations:

• It is recommended that the healthcare provider ensure all medical documentation includes both ICD-10 and CPT codes to prevent claim rejections in the future. The provider should also implement a checklist for claim submissions to verify that all required information is included. Additionally, training for staff on the importance of accurate coding and documentation can help improve the accuracy of future claims. Regular audits of submitted claims can also identify potential discrepancies early in the process, allowing for timely corrections before submission.

Amended Claim:

[Oman] Medical Insurance Claim Report