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CODING DATA REVIEW

In document LAB DX OF UURT (Page 40-45)

Correct procedure and diagnosis coding is critical for uti- lization review and outcome assessment, both of which are used to determine effectiveness of care. For example, a CPT- 4 utilization review can be mapped to specific diagnosis codes to ensure compliance with care pathways. DRG can

be mapped to the clinical outcome (e.g., survival) to deter- mine effectiveness of inpatient care, or DRG can be mapped to the inpatient expense outlay to determine the financial outcome. These are issues which have assumed increasing importance under a new pay-for-performance Medicare reimbursement system. In the case of upper respiratory tract infections, procedure code data may also be used to evaluate compliance with standards of care (e.g., reflex to GAS culture when RADTs are negative for pediatric but not adult patients) or even to assess the performances of individual clinical laboratory scientists by comparing results on more than one procedure performed on a single date of service (e.g., RADT and culture for GAS). There- fore, correct coding has utility not only in ensuring appro- priate reimbursement, but also in evaluating the cost and clinical effectiveness of medical care, including the appro- priateness of testing.

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