Examples

Getting it right. Period.

Patient History Assurance

Example
DOS: September 23, 2013

Diagnosis: 786.6 - Swelling, mass, or lump in chest

Procedure: 23515 - Open treatment of clavicular fracture, includes internal fixation when performed

Amount paid: $1,800

Notes: The main concern when a diagnosis does not create legitimate medical necessity for the reported service is the patients’ continuity of care. Was treatment necessary? Was the patient misdiagnosed? Were the diagnosis or procedure misrepresented on the medical claim? These are the types of questions that are raised in such an event and must be addressed before payment is warranted.

Provider Protection

Example
DOS: January 29, 2014

Diagnosis: 844.9 - Sprain and strain, unspecified site of knee and leg

Procedure: 00100 - Anesthesia for procedures on salivary glands, including biopsy

Amount paid: $137.60

Notes: Diagnoses that do not show legitimate medical necessity for a reported procedure are also an important item for healthcare providers. Medical records that do not support administered procedures may indicate malpractice of several types which include, but are not limited to: failure to diagnose, misdiagnosis of a disease or medical condition, failure to provide appropriate treatment or unreasonable delay in treating a diagnosed medical condition.