Input Document (OCR Source)
Document Type: Radiology Report (scanned PDF) | Language: English (en-ZA) | Pages: 1 | Avg. Confidence: 0.96
RADIOLOGY REPORT FACILITY: City Radiology Partners EXAMINATION: Chest X-Ray PA and Lateral DATE: 03 December 2024 TIME: 14:35 PATIENT: James Wilson, 67-year-old male DOB: 1957-09-22 REFERRING DOCTOR: Dr. Angela Martin, GP CLINICAL INFORMATION: 67-year-old male with 5-day history of productive cough, fever, and shortness of breath. Query pneumonia. Known COPD. TECHNIQUE: PA and lateral chest radiographs performed. Adequate inspiration and penetration. COMPARISON: Previous chest X-ray dated 15 June 2023 FINDINGS: LUNGS: - Right middle and lower lobe consolidation with air bronchograms, consistent with pneumonia - Associated small right pleural effusion (approximately 300ml estimated) - Left lung: No focal consolidation - Background changes of COPD with hyperinflation and flattened hemidiaphragms - No pneumothorax MEDIASTINUM: - Heart size upper limits of normal - Mediastinal contours normal - Aortic arch calcification noted (atherosclerotic changes) IMPRESSION: 1. RIGHT MIDDLE AND LOWER LOBE CONSOLIDATION, CONSISTENT WITH COMMUNITY-ACQUIRED PNEUMONIA 2. SMALL RIGHT PLEURAL EFFUSION (likely parapneumonic) 3. BACKGROUND COPD CHANGES RECOMMENDATION: - Clinical correlation and appropriate antibiotic therapy recommended - Follow-up chest X-ray in 4-6 weeks to confirm resolution ICD-10 CODES: - J18.1: Lobar pneumonia, unspecified organism - J90: Pleural effusion, not elsewhere classified - J44.9: Chronic obstructive pulmonary disease, unspecified PROCEDURE CODES: - 5810: Chest X-ray PA view - 5811: Chest X-ray lateral view REPORTED BY: Dr. Patricia Lee, Radiologist REGISTRATION: MP0777888
OCR Document Extraction Summary
Patient: James Wilson | Member ID: POLY-11122233 | Scheme: Polmed
Document Details
Document Type
Radiology Report (scanned PDF)
Language
English (en-ZA)
Page Count
1
Average Confidence
0.96
Extracted Entities
| Type | Value | Confidence | Notes |
|---|---|---|---|
| Patient | James Wilson | 0.98 | Name extracted from header |
| DOB | 1957-09-22 | 0.99 | Date normalized from DD/MM/YYYY |
| Member ID | POLY-11122233 | 0.95 | Scheme member number |
| Provider | Dr. Patricia Lee (Radiology) | 0.97 | Discipline code resolves to Radiology |
| Practice Number | MP0777888 | 0.99 | HPCSA registration extracted |
| Referring Doctor | Dr. Angela Martin, GP | 0.94 | Referral source identified |
| Service Date | 2024-12-03 | 0.99 | Examination date extracted |
Extracted ICD-10 Codes
| ICD-10 Code | Description | PMB Status | Extraction Source |
|---|---|---|---|
| J18.1 | Lobar pneumonia, unspecified organism | PMB 903D | ICD-10 CODES section + IMPRESSION |
| J90 | Pleural effusion, not elsewhere classified | Non-PMB | ICD-10 CODES section + FINDINGS |
| J44.9 | Chronic obstructive pulmonary disease, unspecified | Non-PMB | ICD-10 CODES section + Clinical Information |
Extracted Procedure Codes
| Original Code | Corrected Code | Description | Bundling Note |
|---|---|---|---|
| 5810 + 5811 | 30110 | X-ray of the chest two views, PA and lateral | Original codes 5810 (PA) and 5811 (Lateral) should be bundled into single code 30110 |
PMB Assessment
Overall Eligibility:eligible
PMB Eligible Conditions
903D - Bacterial, viral, fungal pneumonia
Linked ICD-10: J18.1 | Treatment: Medical management, ventilation
Linked ICD-10: J18.1 | Treatment: Medical management, ventilation
Structured Output (JSON)
{
"patient": {
"name": "James Wilson",
"dob": "1957-09-22",
"memberId": "POLY-11122233",
"scheme": "Polmed"
},
"provider": {
"name": "Dr. Patricia Lee",
"specialty": "Radiology",
"practiceNumber": "MP0777888"
},
"diagnoses": [
{"code": "J18.1", "desc": "Lobar pneumonia", "pmb": "903D", "confidence": 1.0},
{"code": "J90", "desc": "Pleural effusion", "pmb": null, "confidence": 1.0},
{"code": "J44.9", "desc": "COPD, unspecified", "pmb": null, "confidence": 1.0}
],
"procedures": [
{"code": "30110", "desc": "Chest X-ray two views", "originalCodes": ["5810", "5811"]}
]
}Billing Guidance
Recommendations
- Do not submit codes 5810 and 5811. These are identified as invalid/legacy codes. Submit code 30110 (Chest X-ray two views) instead.
- List J18.1 as the primary ICD-10 code to ensure PMB identification.
- Include the referring doctor's practice number (Dr. Angela Martin) on the claim.
- Apply modifier 0092 (Diagnostic services to out-patients) as the patient was referred by a GP and not admitted.
| Potential Issue | Severity | Mitigation |
|---|---|---|
| Invalid Procedure Codes | high | Change 5810/5811 to 30110 prior to submission to prevent automatic rejection. |
| PMB Non-Payment | medium | Ensure ICD-10 J18.1 is primary. If paid from Savings, submit a query to reallocate to Risk benefit under PMB 903D. |
Required Documentation
- Radiology report confirming consolidation.
- Referral letter from Dr. Angela Martin.
Generated by MedCascade | Sample data | Not medical advice