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The Statements of Principles Monitoring, Aetiology and CCPS Commentary Unit

4th floor AMP Place, 10 Eagle St Brisbane Qld 4000.  Facsimile 07 3223 8722

Bob Connolly

07 3223 8325  (Manager)

Dr Jon Kelley

07 3223 8412

Maureen Anderson

08 8290 0365

Sue Lee

08 8290 0227

Duncan Cape

07 3223 8757

Jan Ryan

07 3223 8331

Dr Bev Grehan

07 3223 8376

Vicki Saunders

07 3223 8513

SOP BULLETIN #3

13 November, 1997

DIAGNOSTIC PROTOCOLS IN CCPS

(NEW FORMAT)

As part of its role of providing support to the operational areas with regard to SOP matters and SOPs-in-CCPS matters, the SMACC Unit is working on improving the style and content of Diagnostic Protocols (DPs) on CCPS.

The new DPs are being prepared for all new SOPs, including revoking and amending SOPs, being issued by the RMA as well as for all SOPs being newly-incorporated into CCPS.  In addition, the existing DPs on CCPS will be progressively replaced with the new DPs , commencing with the most frequently-claimed conditions.

DPs appear in CCPS as Commentary when the Confirm Diagnosis screen is being used.   This appears after an ICD code has been selected for the claimed condition.

Confirming the diagnosis is a crucial step in claims processing and mistakes are easily made.

Getting the ICD code and the diagnosis right is essential to providing a fair and just outcome to the claimant because it ensures that the correct RMA SOP and CCPS Rulebase is applied.

It is therefore essential that users read and understand the Diagnostic Protocol which is displayed when an ICD code is selected.  Claims assessors must be satisfied that the words of the definition, in the RMA SOP that applies to the selected ICD code, cover the condition being claimed.  A diagnosis should not be automatically accepted on the strength of an LMO report on a claim form, unless this is OK'd by the DP (in many cases it will be, but there are important exceptions).

The new DPs instruct the Claims Assessor as to what information is required, and from whom, in order to confirm a diagnosis.  They also detail what extra information is essential in order to correctly apply the SOP (e.g. whether you need to know what sub-type of a disease is present).

The new DPs also contain:

  • the RMA SOP definition for the disease;
  • Lists of other relevant diagnoses that are either covered or not covered by the SOP, with guidance on re-encoding, if necessary;
  • General guidance on the extent of investigation that should be undertaken for the purpose of diagnosis; and
  • More detailed comments, when applicable, about important aspects of diagnosis.

The present version of CCPS contains these new-style DP's for the following RMA SOPs:

  • Ischaemic Heart Disease
  • Internal Derangement of the Knee
  • Chronic Bronchitis and Emphysema
  • Asthma
  • Contact Dermatitis
  • Osteoporosis
  • Carpal Tunnel Syndrome
  • Malignant Neoplasm of the Stomach
  • Non-Hodgkins Lymphoma
  • Extrinsic Allergic Alveolitis
  • Photocontact Dermatitis

Therefore, when any of the ICD codes that apply to these particular RMA SOPs is selected on the CCPS Encoder, and the user proceeds to the Confirm Diagnosis screen, the new-style DP for that condition, will be displayed as Commentary.

Following is an example of how these DPs can be viewed in the CCPS Research Library:

  • open CCPS Research;
  • select  ' conditions '  in CCPS;
  • chose  ' neoplasms ';
  • highlight  ' malignant neoplasm of the stomach ',  ' diagnostic protocols ',
  • ' confirmation of diagnosis commentary '  and  ' view '.]

The SMACC Unit aims to make the new DP's as effective and useful as possible.  We therefore welcome any feedback you wish to provide on the new format and contents.