Input Case
Patient: John Smith (DISC-12345678) | Provider: Dr. Sarah Johnson (Internal Medicine) | Scheme: Discovery Health Classic Comprehensive
PATIENT: John Smith, 58-year-old male DATE: 15 December 2024 MEDICAL SCHEME: Discovery Health - Classic Comprehensive CHIEF COMPLAINT: Routine diabetic check-up HISTORY OF PRESENT ILLNESS: Type 2 diabetes mellitus diagnosed 5 years ago. Patient reports progressive numbness and tingling in both feet over the past 6 months. Occasional burning sensation worse at night. No foot ulcers or injuries noted. PAST MEDICAL HISTORY: - Type 2 diabetes mellitus (E11.9) - Hypertension - well controlled on Amlodipine 5mg daily - Hyperlipidemia CURRENT MEDICATIONS: - Metformin 850mg BD - Gliclazide 80mg daily - Amlodipine 5mg daily - Atorvastatin 20mg nocte PHYSICAL EXAMINATION: - Weight: 92kg, Height: 175cm, BMI: 30 - Blood pressure: 138/85 mmHg - Heart rate: 76 bpm, regular - Monofilament test: Reduced sensation bilateral feet - Vibration sense: Decreased at both ankles - Ankle reflexes: Diminished bilateral INVESTIGATIONS ORDERED: - HbA1c (glycated hemoglobin) - Code 3947 - Fasting blood glucose - Code 4001 - Lipid profile - Code 4017 - Urine albumin/creatinine ratio - Code 4048 ASSESSMENT: 1. Type 2 diabetes mellitus with diabetic polyneuropathy (E11.42) 2. Essential hypertension (I10) 3. Mixed hyperlipidemia (E78.2) PLAN: - Optimize glycemic control - target HbA1c < 7% - Add Pregabalin 75mg BD for neuropathic pain - Refer to podiatry for foot care program - Follow-up in 3 months with blood results CONSULTATION: Follow-up consultation - 15 minutes
ICD-10 to RPL Code Alignment & PMB Validation Report
Patient: John Smith | Member ID: DISC-12345678 | Scheme: Discovery Health Classic Comprehensive
ICD-10 Diagnosis Analysis
| ICD-10 Code | Description | PMB Status | Confidence |
|---|---|---|---|
| E11.42 | Type 2 diabetes mellitus with diabetic polyneuropathy | Non-PMB | 100% |
| I10 | Essential (primary) hypertension | PMB 901E | 100% |
| E78.2 | Mixed hyperlipidemia | Non-PMB | 95% |
Clinical Justifications
E11.42: Patient history supports Type 2 DM (5 years) with clear signs of polyneuropathy: 'progressive numbness and tingling', 'occasional burning', 'reduced sensation', 'diminished reflexes'. Code E11.42 is the precise match for DM with polyneuropathy.
Warning: Code listed as Non-PMB in current reference context, despite DM often being a CDL condition. Check specific scheme rules for CDL registration.
I10: Patient has established history of Hypertension, currently treated with Amlodipine. BP 138/85 indicates ongoing management need.
E78.2: History of Hyperlipidemia treated with Atorvastatin. Lipid profile ordered.
Procedure Code Analysis
| RPL Code | Description | Linked ICD-10 | Compliance |
|---|---|---|---|
| 3947 | HbA1c (glycated hemoglobin) | E11.42 | Non-Compliant |
| 4001 | Fasting blood glucose | E11.42 | Non-Compliant |
| 4017 | Lipid profile | E78.2 | Non-Compliant |
| 4048 | Urine albumin/creatinine ratio | I10, E11.42 | Non-Compliant |
Compliance Issues Detected
- 3947: Code 3947 is a pathology tariff code, not a Medical Doctor (RPL) procedure code.
- 4001: Code 4001 is a pathology tariff code.
- 4017: Code 4017 is a pathology tariff code.
- 4048: Code 4048 is a pathology tariff code.
PMB Assessment
Overall Eligibility:partially-eligible
PMB Eligible Conditions
901E - Hypertension - acute life-threatening complications and malignant hypertension
Linked ICD-10: I10 | Treatment: Medical and surgical management
Linked ICD-10: I10 | Treatment: Medical and surgical management
| Diagnosis | Treatment | Procedure | Status | Reason |
|---|---|---|---|---|
| I10 | Medical Management (Amlodipine) | Consultation (Implicit) | valid | Treatment aligns with PMB 901E standards. |
| E11.42 | Medical Management | Pathology | invalid | E11.42 is not listed in the PMB eligible list for this context (unlike E11.5). |
Scheme Considerations
- I10 is a PMB condition (901E). Consultations and investigations related to this should be funded from Risk benefits, not Savings, provided the provider is a DSP or involuntary.
- E11.42 is identified as non-PMB in this context, though typically a Chronic Disease List (CDL) condition. Ensure CDL registration is active to access chronic benefits.
Billing Guidance
Recommendations
- Add a Consultation Code: The case mentions a 'Follow-up consultation - 15 minutes'. This was not coded. Recommended code: 0109 (Follow-up consultation for Physician) or 0108 depending on time/rules.
- Pathology Requisition: Do not include codes 3947, 4001, 4017, 4048 on the doctor's invoice. Issue a pathology request form for the patient to take to the laboratory.
- Link I10 to PMB: Explicitly link I10 to the consultation line item to trigger PMB 901E funding.
- Foot Exam: A monofilament test was performed. If a comprehensive foot assessment was done beyond the standard consult, check if a specific procedure code applies, though usually bundled in the visit.
| Potential Issue | Severity | Mitigation |
|---|---|---|
| Invalid Procedure Codes | high | Remove pathology codes from provider invoice; bill only for consultation. |
| PMB Coverage for Diabetes | medium | E11.42 is not in the provided PMB lookup list (unlike E11.5). Claims may pay from Savings unless CDL registration is confirmed. |
Required Documentation
- Clinical notes supporting the diagnosis of Neuropathy (monofilament test results recorded).
- PMB application form for Hypertension (I10) if not already registered.
Generated by MedCascade | Sample data | Not medical advice