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The clinic dutifully followed the instructions for "E" codes, workman compensation codes. It was a simple fracture of a finger. When the response, with payment, came back, the diagnosis listed was gonorrhea resulting from a fall from aircraft.
Who is to say how this error occurred. Was it the insurance clerk exercising humor, a mistaken entry, a change in code numbers by the commission or an error in theirs or our computer.
Unfortunately, the above is not the only source of spurious diagnosis. In many cases the insurance clerk faced with, looking up the proper ICDA code from the clinician's notes, picks the one that justifies the laboratory and treatment ordered. She does so in order to receive remuneration -- her responsibility. Even when the clinician lists the appropriate ICDA, the clerk may likely change it in order to met the criteria for payment. This manipulation of diagnostic code might be considered fraud. On the other hand, the clinic provided an honest service, rendered a diagnosis that may not exactly fit the codes and criteria. The clerk is fulfilling her duty to the clinic, the coding system and the patient. The clinic is therefore resolving ambiguities in good faith. However, the coded diagnosis may not accurately reflect the diagnosis for the patient.
Moreover, many clinicians are reluctant to record any diagnosis that the insurance company can call a preexisting condition. A noble concern, but one that erodes the acknowledgement of early risk or the identification of incipient disease.
When one adds to these sources of erroneous diagnosis and the all to frequent missed or wrong diagnosis, there results a database of demographics and diagnosis that is corrupt from the start. A system of confirmed diagnosis might help.
Will the ACA or the EHR eliminate these sources of error? Probably not, the patient confidentiality issue remains. Even though the insurance company may no longer be able to deny preexisting conditions, the patient information is none the less in their database. The draconian rules limiting access to patient data makes it difficult for clinicians to coordinate care or the patient to access his or her information; whereas the system makes the information readily available to insurance companies and government. If Equifax wants to know if you have HIV, they are going to find out.
Lastly, how do you know that the diagnosis is correct even at best. Autopsy results find as much as 60% missed or wrong diagnosis. That is not to say that missed or wrong diagnosis occurs 60% of the time, but among patients who die, the missed or wrong diagnosis may be critical information. Shamefully, autopsy is a thing of the past. Blame it on families, fears of litigation, cost or hospital inconvenience, a revenue issue. Autopsy is the final analysis, but who will pay for it?
The clinic dutifully followed the instructions for "E" codes, workman compensation codes. It was a simple fracture of a finger. When the response, with payment, came back, the diagnosis listed was gonorrhea resulting from a fall from aircraft.
Who is to say how this error occurred. Was it the insurance clerk exercising humor, a mistaken entry, a change in code numbers by the commission or an error in theirs or our computer.
Unfortunately, the above is not the only source of spurious diagnosis. In many cases the insurance clerk faced with, looking up the proper ICDA code from the clinician's notes, picks the one that justifies the laboratory and treatment ordered. She does so in order to receive remuneration -- her responsibility. Even when the clinician lists the appropriate ICDA, the clerk may likely change it in order to met the criteria for payment. This manipulation of diagnostic code might be considered fraud. On the other hand, the clinic provided an honest service, rendered a diagnosis that may not exactly fit the codes and criteria. The clerk is fulfilling her duty to the clinic, the coding system and the patient. The clinic is therefore resolving ambiguities in good faith. However, the coded diagnosis may not accurately reflect the diagnosis for the patient.
Moreover, many clinicians are reluctant to record any diagnosis that the insurance company can call a preexisting condition. A noble concern, but one that erodes the acknowledgement of early risk or the identification of incipient disease.
When one adds to these sources of erroneous diagnosis and the all to frequent missed or wrong diagnosis, there results a database of demographics and diagnosis that is corrupt from the start. A system of confirmed diagnosis might help.
Will the ACA or the EHR eliminate these sources of error? Probably not, the patient confidentiality issue remains. Even though the insurance company may no longer be able to deny preexisting conditions, the patient information is none the less in their database. The draconian rules limiting access to patient data makes it difficult for clinicians to coordinate care or the patient to access his or her information; whereas the system makes the information readily available to insurance companies and government. If Equifax wants to know if you have HIV, they are going to find out.
Lastly, how do you know that the diagnosis is correct even at best. Autopsy results find as much as 60% missed or wrong diagnosis. That is not to say that missed or wrong diagnosis occurs 60% of the time, but among patients who die, the missed or wrong diagnosis may be critical information. Shamefully, autopsy is a thing of the past. Blame it on families, fears of litigation, cost or hospital inconvenience, a revenue issue. Autopsy is the final analysis, but who will pay for it?
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