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Number of diagnoses or Treatment Options

  1. Default Number of diagnoses or Treatment Options
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    Hello fellow auditors.

    I have always been easily confused on how to count/quantify the # of diagnoses or Treatment Options.

    Especially when considering what I can allow for the provider.

    If a new problem arises due to medication do you count it as a new problem with or without additional workup.? Then if the provider treats/manages that medication complication does the provider get credit for it on every visit where it is re-evaluated?

    for example:

    The oncologist is treating a cancer patient.

    During treatment the patient developes constipation, decreased apetite and a skin fungal infection. The Oncologist manges each of the problems with OTC and or RX. then reasses the problems at each recheck.

    If the patient is still recieveing chemo and cancer is still present I give them 2 points for the established problem, I consider this worsening until we have evidence the chancer has gone into remission. ( I know carriers deny using a point system but lets face it thats all we have)
    Then one point for each of the complications of chemo if stable/improved which most of them are.

    So for this example we are looking at 5 points/options for problems to the examining physician. Agree?

    I really need your expert opinoins.

    Thank You

  2. #2
    Rose City (Portland, Oregon)
    I count the cancer as est stable/resolving if the documentation shows NED or tumor shrinking or some other evidence that it is getting better. Otherwise I count it as est worsening, not controlled.

    As for the new issues, I would count them as either minor problems or new prob undiagnosed depending on what the problem is (constipation might be minor but anemia would be new prob). For the subsequent visits, if the MD is addressing them in that visit, not just a cursory mention of "no more problems with x", I would count them as either minor problems or est stable or worsening depending on the issue/status.

    Hope that helps.

    CPC, CHC

  3. Default
    Medical Billing
    Thank you, your advice helps alot. I really feel that the Hematology/oncology practice is at low risk for carrier audits. Our State carrier likes to go after the big groups like ER or NICU.
    Have you ever had a carrier audit? And if so was the Carrier in agreement with your audits?
    We have had our Medicaid carrier ask why we had more high level codes than the rest of the state. SInce we are Pediatrics it was easy to explain and I have never heard back from them.
    Thanks again

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