Wiki Hypoxemia - auditing

Create Wiki
S

sammie06

Networker
Messages
47
Location
Bend , OR
Best answers
0
Hi
When auditing hypoxemia what are the things you look for ABG test, blood test, pulse oximetry etc to validate that the patient has hypoxemia. Help :confused:
 
As a coder or nonphysician auditor it is not our place to determine what if any clinical evidence is required to determine a dx. Our job is to see if the dx is docuemnted by the physician.
 
That is true, however as a HCC auditor we are required to verify additional information besides what the doctor documents - we typically also looks at labs, CT scan x-ray
 
Ok I am still trying to figure out why you would need to question whether the physicians data is sufficient for a diagnosis. If you are not a trained medical practitioner how can you make these determinations. I am being a devils advocate here but I am getting some physician feedback on this and passing this on. He needs to know why a coder or an auditor without the right medical background would question a diagnosis based on the lab values present in the chart. Help me here, because I asked him the question above and this is what I am getting back.
 
I am a CPC and I work for a company that does Medicare Risk Adjustment. We basically are working for the payer. When you code for risk adjustment, you are reviewing the medical record and verifying that the diagnoses given by the provider are validated in the note. So, for example, if the physician gives a diagnosis of hypoxemia, what did he do to treat that? How is that supported in the medical record? Is the patient on oxygen, what tests were done, etc? We're not questioning the doctor's diagnosis - it is what it is. It's just that for our purposes, he doesn't get credit for that diagnosis if it's not supported.
 
mitchellde said:
Ok I am still trying to figure out why you would need to question whether the physicians data is sufficient for a diagnosis. If you are not a trained medical practitioner how can you make these determinations. I am being a devils advocate here but I am getting some physician feedback on this and passing this on. He needs to know why a coder or an auditor without the right medical background would question a diagnosis based on the lab values present in the chart. Help me here, because I asked him the question above and this is what I am getting back.
Click to expand...

I have done a little of the HCC coding. These claims have already been billed and paid by the appropriate payors and all that these coders do AFTER the fact is take the documentation and determine current chronic conditions. This is because even though these claims are paid to the providers already, there is an incentive paid back to the payor based on chronic conditions of their insured patients and this will determine (for them) the $$$ amount of care they will need for the next year. It is confusing to me a little but these coders are not doing anything illegal I assure you!
 
I am not questioning the legality I am questioning whether the person evaluating this information has the necessary medical knowledge to know what they are looking at. The physician I posed this issue to is very concerned about the same thing.
 
While I understand your concern, I assure you there is no need. This is an internal process with the Medicare plan and has nothing to do with treating/diagnosing patients, etc... It is merely a way for them to capture CURRENT chronic conditions for their subscribers. So if the patient has a "history of" something... and is currently taking a medication for it then this would be assessed as a CURRENT chronic condition and would be coded according to the guidelines set by the payor for this process (HCC coding process). Simple. There is a link on the CMS website for Medicare Advantage and I don't know if it will shed any light for you and your provider about this issue but it's worth a try. Maybe someone else out there can explain this process better than me but it's really nothing to be concerned about. Good luck!!
 
You must log in or register to reply here.
Top