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predict medical codes: ICD-10-AM coding per Saudi CHI classification — PREGNANCY, CHILDBIRTH AND THE PUERPERIUM:
Diagnosis codes: S17.0:Crushing injury of larynx and trachea; O85:Puerperal sepsis; S14.2:Injury of nerve root of cervical spine; Q74.2:Other and unspecified congenital malform; Q89.89:Other specified congen... | {"denial_codes":["SE1-8","SE1-6"],"icd10":["S17.0","O85","S14.2"],"sbs":["90467-00-00","16564-00-00","90484-01-00"],"sfda":["117-186-00","2201233140","0409222581"]} |
predict medical codes: CHI mandatory policy audit finding:
Claim audit for Obstetrics encounter:
− Patient diagnosed with Rheumatoid arthritis, seropositive
− echocardiography performed and billed
− Prescribed: Pantoprazole 40mg, Levetiracetam 500mg, Insulin Glargine 100IU/mL
− Audit finding: CV4-6 — exceeded approved ... | {"denial_codes": ["CV4-6", "AD1-6"], "icd10": ["E13.0", "E13.39"], "sbs": ["30562-00-00"], "sfda": ["1506233815"]} |
predict medical codes: Discharge summary coding review — Saudi CHI standards:
Patient admitted under Neurology with Acute ST-elevation myocardial infarction.
During hospitalisation:
− hernia repair performed on day 1
− Medications: Sertraline 50mg
− Complications: post-procedural bleeding
All active diagnoses cod... | {"denial_codes": ["CV4-5", "AD1-3", "CV1-4"], "icd10": ["P96.52"], "sbs": ["38481-02-00"], "sfda": ["25-430-19", "25-191-15", "1805257411"]} |
predict medical codes: CHI mandatory policy audit finding:
Claim audit for Dermatology encounter:
− Patient diagnosed with Type 2 diabetes mellitus with complications
− echocardiography performed and billed
− Prescribed: Salbutamol 100mcg MDI
− Audit finding: SE1-3 — exceeded approved duration
− Corrective action requi... | {"denial_codes": ["SE1-3"], "icd10": ["O24.42", "O07"], "sbs": ["73050-40-90"], "sfda": ["2401210466", "0105233566", "1307233870"]} |
predict medical codes: Insurance claim submitted for clinical scenario:
Department: Paediatrics
Diagnosis: Pulmonary embolism
Procedure: caesarean section
Medications: Furosemide 40mg, Dexamethasone 4mg
Documentation reviewed per CHI mandatory policy.
Prior authorization: expired — resubmission required
Potential denia... | {"denial_codes": ["CV4-1", "SE1-4"], "icd10": ["C31", "C67.3", "C24"], "sbs": ["97643-00-80"], "sfda": ["168-172-09"]} |
predict medical codes: ICD-10-AM coding per Saudi CHI classification — DISEASES OF THE SKIN AND SUBCUTANEOUS TISSUE:
Diagnosis codes: M25.63:Stiffness of joint, not elsewhere classi; M48.02:Spinal stenosis, cervical region; M83.84:Other adult osteomalacia, hand; M85.07:Fibrous dysplasia (monostotic), ankle an; M94.24:C... | {"denial_codes":["CV1-3","MN1-1"],"icd10":["M25.63","M48.02","M83.84"],"sbs":["45590-00-01","45723-00-00","45442-00-00"],"sfda":["20-539-09","1907233881","0905233616"]} |
predict medical codes: Medical necessity review — Saudi MOH/CHI guidelines:
Sepsis due to E. coli bacteraemia management per Saudi CHI/MOH protocol:
− Gastroenterology consultation with documented clinical assessment
− Procedure: total knee replacement with documented indication
− Medications: Ceftriaxone 1g
− Claims r... | {"denial_codes": ["AD1-7", "CV4-5"], "icd10": ["I73.1"], "sbs": ["90603-07-02", "36664-00-00"], "sfda": ["0908222442"]} |
predict medical codes: Insurance claim submitted for the following clinical scenario:
Upper GI bleeding management per Saudi MOH Gastroenterology Protocol:
− Rockford score or Glasgow-Blatchford score at presentation
− IV Omeprazole 80 mg bolus then 8 mg/hr infusion for suspected peptic ulcer bleed
− Urgent OGD within ... | {"denial_codes":["SE1-6"],"icd10":["K92.0","K25.0","K26.0"],"sbs":["83600-00-90","32090-00-00"],"sfda":["0912246377"]} |
predict medical codes: Discharge summary coding review — Saudi CHI standards:
Patient admitted under Paediatrics with Community-acquired pneumonia.
During hospitalisation:
− total knee replacement performed on day 3
− Medications: Ceftriaxone 1g, Omeprazole 20mg
− Complications: post-procedural bleeding
All activ... | {"denial_codes": ["SE1-8", "CV1-5"], "icd10": ["N18", "N31.0", "N18.4"], "sbs": ["45451-23-02", "49703-05-01"], "sfda": ["41-261-19", "1610234337"]} |
predict medical codes: Pharmacy dispensing record — outpatient prescription:
Patient collected the following medications from the hospital outpatient pharmacy:
− Metformin 1000mg
− Sertraline 50mg
− Enoxaparin 40mg
− Meropenem 1g
All items dispensed as per physician prescription. SFDA registration verified for ... | {"denial_codes": null, "icd10": ["K04.9"], "sbs": null, "sfda": ["1501268924"]} |
predict medical codes: SFDA-registered immunosuppressants medications — ATC L04 per Saudi CHI formulary policy:
Medications: LENALIDOMIDE(SOTIRA 25MG CAPSULE, Capsule, hard, 25mg,); TACROLIMUS(ADVAGRAF 5MG PROLONGED RELEASE CAPSULE, Prolonged-release capsule, hard, 5mg,); GOLIMUMAB(SIMPONI 100 MG/ML SOLUTION FOR INJECT... | {"denial_codes":["CV4-5","CV4-1","SE1-6"],"icd10":["C84.5","C65","C18.8"],"sbs":["83600-03-10","83600-00-11","83600-02-61"],"sfda":["1102256869","2803245120","4-842-17"]} |
predict medical codes: Medical necessity review — Saudi MOH/CHI guidelines:
Pre-eclampsia with severe features management per Saudi CHI/MOH protocol:
− Emergency Medicine consultation with documented clinical assessment
− Procedure: CT abdomen with contrast with documented indication
− Medications: Warfarin 5mg
− Claim... | {"denial_codes": ["CV4-5"], "icd10": ["O92.30", "O71.0", "O92.2"], "sbs": ["47771-00-01", "61473-00-00", "90225-02-00"], "sfda": ["0311258538"]} |
predict medical codes: Clinical coding validation per CHI/MOH standards:
Breast cancer management per Saudi MOH Oncology Protocol:
− Trastuzumab 8 mg/kg loading then 6 mg/kg q3 weeks for HER2-positive
− Echocardiography (LVEF) before Trastuzumab and every 3 months
− Hormonal therapy: Tamoxifen for pre-menopausal; Aroma... | {"denial_codes":["SE1-6"],"icd10":["C50.9","C50.1","C50.4"],"sbs":["14100-00-00","83600-00-20"],"sfda":["0311258535","2-5761-23","0802233223"]} |
predict medical codes: Revenue cycle management denial analysis:
Epilepsy management per Saudi MOH Neurology Protocol:
− First seizure: EEG and MRI brain mandatory before initiating antiepileptic therapy
− Focal epilepsy first-line: Levetiracetam 250–500 mg BD or Carbamazepine 100–200 mg BD
− Generalised epilepsy: Valp... | {"denial_codes":["SE1-6"],"icd10":["G40.2","G40.0","G40.9"],"sbs":["83600-00-20","83600-02-60"],"sfda":["3-5128-19","0710258335","0806233777"]} |
predict medical codes: ICD-10-AM coding per Saudi CHI classification — EXTERNAL CAUSES OF MORBIDITY AND MORTALITY:
Diagnosis codes: V75.99:Bus occupant injured in collision with r; W85.83:Exposure to electric transmission lines,; X62.02:Intentional self-poisoning by and exposu; W32.02:Handgun discharge, home, while wor... | {"denial_codes":["SE1-8","SE1-10"],"icd10":["V75.99","W85.83","X62.02"],"sbs":["83520-00-00","83530-00-10","83500-00-20"],"sfda":["1405245286","0109222570","0403256981"]} |
predict medical codes: Stroke prevention in AF per Saudi CHI/MOH protocol:
− Anticoagulation indicated for CHA₂DS₂-VASc ≥2 (men) or ≥3 (women)
− DOACs (Rivaroxaban 20 mg OD, Apixaban 5 mg BD) preferred over Warfarin for non-valvular AF
− Warfarin (INR 2.0–3.0) for AF with mechanical valves or mitral stenosis
− CHA₂DS₂-... | {"denial_codes":["MN1-1","CV4-1"],"icd10":["I48.0","I48.1","I48.9"],"sbs":["83600-00-10","83600-00-20"],"sfda":["54-4-13","0211234420","1-5550-20"]} |
predict medical codes: Poisoning, self-harm, and intentional injury coding per Saudi MOH protocol:
External cause codes for this clinical episode:
− X01.79: Exposure to uncontrolled fire, not in building or structure, farm, dur
− X71.2: Intentional self-harm by drowning and submersion in natural water
− X81.8: In... | {"denial_codes":["CV1-5"],"icd10":["X01.79","X71.2","X81.8"],"sbs":["83600-00-90","83000-00-02","83600-01-70"],"sfda":["1111246178","16-535-14","2108258081"]} |
predict medical codes: SBS procedure claims — Non-invasive, cognitive and other interventions, not elsewhere classified** per Saudi CHI protocol:
Billed procedures: 92090-00-00:R/O FB from rectum or anus wo incis; 96202-04-00:Enteral admin of pharmac agent anti; 90595-00-92:Applic/rev/immobil/ support device ; 92094-00... | {"denial_codes":["SE1-6","SE1-8","MN1-1"],"icd10":["A03.0","A02.2","A01.0"],"sbs":["92090-00-00","96202-04-00","90595-00-92"],"sfda":["2703233429","2609211077","215-149-00"]} |
predict medical codes: ICD-10-AM coding per Saudi CHI classification — EXTERNAL CAUSES OF MORBIDITY AND MORTALITY:
Diagnosis codes: V34.52:Occupant of three-wheeled motor vehicle ; W51.18:Striking against or bumped into by anoth; W32.3:Handgun discharge, sports and athletics ; V56.50:Occupant of pick-up truck or van in... | {"denial_codes":["SE1-10"],"icd10":["V34.52","W51.18","W32.3"],"sbs":["83520-00-00","83500-00-20","83500-00-10"],"sfda":["425-149-16","144-149-98","82-149-95"]} |
predict medical codes: Discharge summary coding review — Saudi CHI standards:
Patient admitted under General Surgery with Rheumatoid arthritis, seropositive.
During hospitalisation:
− percutaneous coronary intervention performed on day 2
− Medications: Meropenem 1g, Enoxaparin 40mg
− Complications: hospital-acqui... | {"denial_codes": ["SE1-7", "SE1-5"], "icd10": ["R39.1", "R93.7"], "sbs": ["97643-00-30", "33839-03-01", "73350-05-00"], "sfda": ["1606222216"]} |
predict medical codes: Insurance claim — compliant submission per CHI standards:
Department: Obstetrics
Diagnosis: Major depressive disorder, moderate, recurrent
Treatment: Amlodipine 5mg, Vancomycin 1g, Ciprofloxacin 500mg
All documentation complete. Prior authorization verified. SFDA registration confirmed.
Diagnosis... | {"denial_codes": null, "icd10": ["J13", "J96.1", "J98.4"], "sbs": ["42848-00-01", "38200-00-00"], "sfda": ["256-149-02"]} |
predict medical codes: ICD-10-AM diagnosis coding — ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES per Saudi CHI classification standards:
Applicable diagnosis codes for this clinical episode:
− E87.6: Hypokalaemia
− E44.0: Moderate protein-energy malnutrition
− E63: Other nutritional deficiencies
− E61.9: Defic... | {"denial_codes":["SE1-8","SE1-6","MN1-1"],"icd10":["E87.6","E44.0","E63"],"sbs":["47033-00-01"],"sfda":["1110211115","2308222532","2305210743"]} |
predict medical codes: Discharge summary coding review — Saudi CHI standards:
Patient admitted under Obstetrics with Acute ST-elevation myocardial infarction.
During hospitalisation:
− appendectomy performed on day 2
− Medications: Levetiracetam 500mg
− Complications: hospital-acquired infection
All active diagno... | {"denial_codes": ["AD3-8", "AD1-5", "CV4-1"], "icd10": ["M94.91", "M24.2", "M95.9"], "sbs": ["58721-00-00"], "sfda": ["2303257132", "1507210879", "1505257395"]} |
predict medical codes: MOH Surgical Safety Checklist Implementation Guide — DRAFT | Page 60
Council of Health Insurance | Kingdom of Saudi Arabia | 2022
This page intentionally left blank. | {"denial_codes": null, "icd10": null, "sbs": null, "sfda": null} |
predict medical codes: ANNEX E: Patient Information Leaflet (Arabic)
[This annex contains a template form. The content is structural — field labels, checkboxes, and blank lines for handwritten data. No clinical information is present in the template itself.] | {"denial_codes": null, "icd10": null, "sbs": null, "sfda": null} |
predict medical codes: SBS procedure claims — Procedures on digestive system per Saudi CHI protocol:
Billed procedures: 32094-00-00:Endoscopic dilation colorectal stri; 30527-00-00:Fundoplasty laparoscopic approach; 30581-00-00:Exploration of pancreas; 90376-02-00:R/O peritoneal access device
Documentation: pre-proce... | {"denial_codes":["SE1-6","SE1-8"],"icd10":["A03.1","A01.0","A00.0"],"sbs":["32094-00-00","30527-00-00","30581-00-00"],"sfda":["1312223012","20-290-03","2904221998"]} |
predict medical codes: Saudi MOH Chronic Kidney Disease Management Protocol
TABLE OF CONTENTS
1. Special Populations ..................... 55
2. Paediatric Considerations ............... 23
3. Abbreviations and Acronyms .............. 23
4. Follow-up and Monitoring ................ 69
5. Surgical Management... | {"denial_codes": null, "icd10": null, "sbs": null, "sfda": null} |
predict medical codes: MOH Childhood Immunization Schedule and Guidelines
COPYRIGHT AND DISCLAIMER
© 2016 Council of Health Insurance, Kingdom of Saudi Arabia. All rights reserved.
This document may be freely reproduced for educational and non-commercial purposes with appropriate citation. Commercial use requires wr... | {"denial_codes": null, "icd10": null, "sbs": null, "sfda": null} |
predict medical codes: Urology procedure claim per Saudi CHI protocol:
Billed SBS codes:
− 36842-00-00: Endosc lavage blood clots from bladder
− 37029-01-00: Abdominal closure vesicovaginal fistula
− 13109-00-00: Ins & fix indwel peritonl cath long term
− 90350-00-00: Other repair of kidney
Documentation: urine... | {"denial_codes":["SE1-8","SE1-6"],"icd10":["S45.7","X78.63","W06.54"],"sbs":["36842-00-00","37029-01-00","13109-00-00"],"sfda":["0206222125","25-346-08","2403257139"]} |
predict medical codes: CHI mandatory policy audit finding:
Claim audit for Internal Medicine encounter:
− Patient diagnosed with Deep vein thrombosis, left leg
− hernia repair performed and billed
− Prescribed: Enoxaparin 40mg
− Audit finding: MN1-2 — diagnosis-procedure mismatch
− Corrective action required before cla... | {"denial_codes": ["MN1-2", "AD3-6"], "icd10": ["C44.7", "C69.9", "C24.9"], "sbs": ["61390-00-00", "49312-00-00", "49221-01-01"], "sfda": ["2-5825-23", "1012258771"]} |
predict medical codes: Medical necessity review — Saudi MOH/CHI guidelines:
Provider type mismatch per Saudi CHI mandatory coding policy:
− A primary care general practice clinic submitted a claim for bone marrow biopsy (SBS 14103-00-00) with diagnosis of suspected acute leukaemia (ICD-10 C91.0).
− Bone marrow aspirati... | {"denial_codes":["AD1-5","SE1-8","MN1-1"],"icd10":["C91.0","C91.9"],"sbs":["83600-00-20"],"sfda":["0802233223"]} |
predict medical codes: Medical necessity review — Saudi MOH/CHI guidelines:
Chronic kidney disease stage 4 management per Saudi CHI/MOH protocol:
− Gastroenterology consultation with documented clinical assessment
− Procedure: bone marrow biopsy with documented indication
− Medications: Warfarin 5mg, Dexamethasone 4mg
... | {"denial_codes": ["AD1-4"], "icd10": ["V66.78", "V34.6"], "sbs": ["73050-45-50"], "sfda": ["0711246161", "0105245234"]} |
predict medical codes: Insurance claim submitted for clinical scenario:
Department: Endocrinology
Diagnosis: Crohn disease of ileum
Procedure: CT abdomen with contrast
Medications: Atorvastatin 40mg
Documentation reviewed per CHI mandatory policy.
Prior authorization: expired — resubmission required
Potential denial tr... | {"denial_codes": ["CV4-6", "CV4-1"], "icd10": ["C84.4", "C06.1", "C78.3"], "sbs": ["32005-02-00", "41509-00-01", "92512-39-02"], "sfda": ["1003221839", "2305210745", "3001233193"]} |
predict medical codes: CHI mandatory policy audit finding:
Gender-procedure inconsistency per Saudi CHI coding validation:
− A patient registered as female in the insurance system was billed for prostate biopsy (37219-00-00) and PSA screening.
− Cross-referencing HIS records confirmed the patient is male — a registrati... | {"denial_codes":["AD3-8","AD3-6","SE1-7"],"icd10":["C61","Z12.5"],"sbs":["83600-00-20"],"sfda":["none"]} |
predict medical codes: Saudi MOH Chronic Kidney Disease Management Protocol
GLOSSARY OF TERMS AND ABBREVIATIONS
The following definitions apply throughout this document:
NIHSS: National Institutes of Health Stroke Scale — a standardised assessment of stroke severity
MOH: Ministry of Health — the primary governm... | {"denial_codes": null, "icd10": null, "sbs": null, "sfda": null} |
predict medical codes: Quality assurance review of clinical documentation:
Acute decompensated heart failure per MOH Emergency Protocol:
− IV Furosemide bolus 40–80 mg (or 2× daily oral dose) for fluid overload
− Monitor urine output, daily weight, electrolytes
− IV GTN for hypertensive ADHF (SBP >140 mmHg)
− Non-invas... | {"denial_codes":["SE1-8","SE1-6","CV1-5"],"icd10":["I50.0","I50.9"],"sbs":["83600-00-90","13882-00-00","83000-00-02"],"sfda":["3-152-87","0907245514","20-349-11"]} |
predict medical codes: Per Saudi MOH clinical protocol review:
Surgical antibiotic prophylaxis per Saudi MOH Infection Control Protocol:
− First dose within 60 minutes before skin incision (Vancomycin within 120 minutes)
− Clean procedures: Cefazolin 1–2 g IV
− Colorectal surgery: Cefazolin + Metronidazole
− Duration: ... | {"denial_codes":["AD1-3","CV4-2"],"icd10":["Z48.0","Z87.0","K40.0"],"sbs":["30445-00-00","30571-00-00"],"sfda":["15-390-06","1108222475"]} |
predict medical codes: Mortality and morbidity review — retrospective case discussion:
Case presented at departmental M&M conference on 2023-09-20.
Patient: 44-year-old female admitted with massive pulmonary embolism.
Timeline of events reviewed. Root cause analysis: delay in escalation identified — action plan created... | {"denial_codes": null, "icd10": ["B71.9", "B96.7", "B79"], "sbs": null, "sfda": null} |
predict medical codes: Transport accident injury coding per Saudi MOH/CHI Emergency guidelines:
The following ICD-10-AM external cause codes document the mechanism of a road traffic accident:
− V38.40: Occupant of three-wheeled motor vehicle injured in noncollision transp
− V77.41: Bus occupant injured in collision... | {"denial_codes":["SE1-1","AD1-3","SE1-10"],"icd10":["V38.40","V77.41","V58.48"],"sbs":["83600-00-90","83000-00-02","73050-04-60"],"sfda":["30-346-10","1901221616"]} |
predict medical codes: Antenatal care schedule per Saudi MOH Obstetric Protocol:
− Booking visit ≤12 weeks: FBC, blood group, rubella, HIV, hepatitis B/C, VDRL
− 18–20-week anomaly scan: detailed fetal structural survey
− 24–28 weeks: 75g OGTT for GDM screening; FBC for anaemia
− 36 weeks: presentation check; Group B S... | {"denial_codes":["SE1-6"],"icd10":["Z34.0","Z34.9"],"sbs":["83600-00-10","16520-02-00"],"sfda":["1807245611","40-490-08"]} |
predict medical codes: MOH National Tuberculosis Control Programme Manual
COPYRIGHT AND DISCLAIMER
© 2021 Council of Health Insurance, Kingdom of Saudi Arabia. All rights reserved.
This document may be freely reproduced for educational and non-commercial purposes with appropriate citation. Commercial use requires wr... | {"denial_codes": null, "icd10": null, "sbs": null, "sfda": null} |
predict medical codes: ICD-10-AM coding per Saudi CHI classification — EXTERNAL CAUSES OF MORBIDITY AND MORTALITY:
Diagnosis codes: X35.73:Victim of volcanic eruption, farm, while; W13.22:Fall from, out of or through building or; X63.7:Intentional self-poisoning by and exposu; X40.31:Accidental poisoning by and exposur... | {"denial_codes":["SE1-8"],"icd10":["X35.73","W13.22","X63.7"],"sbs":["83530-00-30","83540-00-10","83510-00-10"],"sfda":["9-483-15","1802244939","190-149-99"]} |
predict medical codes: ICD-10-AM coding per Saudi CHI classification — EXTERNAL CAUSES OF MORBIDITY AND MORTALITY:
Diagnosis codes: X05.09:Exposure to ignition or melting of night; W91.93:Exposure to unspecified type of radiatio; V85.20:Person on outside of special constructio; V10.10:Pedal cyclist injured in collision... | {"denial_codes":["SE1-10","SE1-8","AD1-3"],"icd10":["X05.09","W91.93","V85.20"],"sbs":["83530-00-20","83500-00-50","83530-00-30"],"sfda":["1311246217","155-149-98","0109222576"]} |
predict medical codes: Post-payment audit clinical review:
Age and gender consistency in clinical coding per CHI standards:
− Paediatric diagnosis (e.g., febrile convulsion R56.0) submitted for adult patient (>18 years) without documented developmental condition triggers AD3-5
− Prostate biopsy (37219-00-00) for female... | {"denial_codes":["AD3-5","AD3-6"],"icd10":["R56.0","N39.0","P59.9"],"sbs":["83600-00-10","83600-00-90"],"sfda":["0603245023","1802256914"]} |
predict medical codes: SFDA-registered antineoplastics medications — ATC L01 per Saudi CHI formulary policy:
Medications: FLUDARABINE PHOSPHATE(FLUDARA 10MG F.C TABLETS, Film-coated tablet, 10mg,); PACLITAXEL(Ebetaxel 30mg/5ml, Concentrate for solution for infusion, 6mg/ml); AZACITIDINE(Dazaspect, Lyophilisate for solu... | {"denial_codes":["CV4-5","CV4-2"],"icd10":["D42.0","D22.5","C41.3"],"sbs":["37200-03-00","31524-01-00","37616-01-00"],"sfda":["1-832-12","36-355-06","0901244689"]} |
predict medical codes: Clinical documentation review per Saudi CHI standards:
Inpatient encounter — Internal Medicine department:
Principal diagnosis: Pre-eclampsia with severe features
Primary procedure: echocardiography
Pharmacotherapy: Levetiracetam 500mg, Vancomycin 1g
LOS: 17 days. ICU days: 3.
All diagnoses coded... | {"denial_codes": ["CV1-5", "SE1-2"], "icd10": ["E78.9", "E20.9", "E85"], "sbs": ["41554-00-01", "83600-02-50"], "sfda": ["0701256539", "24-367-13"]} |
predict medical codes: ICD-10-AM coding per Saudi CHI classification — EXTERNAL CAUSES OF MORBIDITY AND MORTALITY:
Diagnosis codes: Y23.51:Rifle, shotgun and larger firearm discha; X62.91:Intentional self-poisoning by and exposu; W22.2:Striking against or struck by other obje; X64.89:Intentional self-poisoning by and e... | {"denial_codes":["SE1-10","AD1-3","SE1-8"],"icd10":["Y23.51","X62.91","W22.2"],"sbs":["83500-00-50","83530-00-00","83530-00-20"],"sfda":["17-149-91","13-5010-19","1311246213"]} |
predict medical codes: SFDA-registered ophthalmologicals medications — ATC S01 per Saudi CHI formulary policy:
Medications: PHENYLEPHRINE HYDROCHLORIDE(MYDFRIN 2.5% DROPS, Eye drops, solution, 2.5%,); GATIFLOXACIN(ZYMAXID 0.5% eye drops solution, Ophthalmic solution, 0.5%,); ACETAZOLAMIDE(Acetazolamide, Tablet, 250mg,)... | {"denial_codes":["MN1-1","CV4-5"],"icd10":["H50.5","H53.1","H59.85"],"sbs":["42593-00-01","42542-01-02","42764-00-01"],"sfda":["1610246063","1303257050","1202256891"]} |
predict medical codes: CHI mandatory policy audit finding:
Claim audit for Obstetrics encounter:
− Patient diagnosed with Acute exacerbation of COPD
− coronary angiography performed and billed
− Prescribed: Amlodipine 5mg
− Audit finding: CV1-5 — incomplete documentation
− Corrective action required before claim resubm... | {"denial_codes": ["CV1-5", "AD1-2", "CV4-6"], "icd10": ["Q32.4", "Q83.2", "Q60.6"], "sbs": ["73350-00-50", "42805-00-01", "42644-05-01"], "sfda": ["38-136-11", "0108222386", "1111258569"]} |
predict medical codes: Medical necessity review — Saudi MOH/CHI guidelines:
Chronic kidney disease stage 4 management per Saudi CHI/MOH protocol:
− Psychiatry consultation with documented clinical assessment
− Procedure: laparoscopic cholecystectomy with documented indication
− Medications: Pantoprazole 40mg, Warfarin ... | {"denial_codes": ["SE1-2", "SE1-7"], "icd10": ["D56.0"], "sbs": ["35303-07-00"], "sfda": ["2003245065"]} |
predict medical codes: Clinical documentation review per Saudi CHI standards:
Inpatient encounter — Orthopaedics department:
Principal diagnosis: Liver cirrhosis, Child-Pugh B
Primary procedure: appendectomy
Pharmacotherapy: Ciprofloxacin 500mg, Bisoprolol 5mg
LOS: 17 days. ICU days: 1.
All diagnoses coded per ICD-10-A... | {"denial_codes": ["CV4-5", "AD1-2"], "icd10": ["T36.0"], "sbs": ["48678-00-00", "42652-00-11", "38390-02-00"], "sfda": ["2510222791", "1910222760"]} |
predict medical codes: SBS procedure claims — Laboratory and Pathology per Saudi CHI protocol:
Billed procedures: 73050-14-50:Arterial blood gas (ABG); 73350-02-71:SERPINA1 gene; variants; 73050-11-10:Deoxycortisol; 73050-10-70:Cystine & Homocystine
Documentation: pre-procedure workup, indication, informed consent, pos... | {"denial_codes":["SE1-3","SE1-6","SE1-7"],"icd10":["A03.0","A02.8","A01.3"],"sbs":["73050-14-50","73350-02-71","73050-11-10"],"sfda":["2310258477","2903233444","2307257823"]} |
predict medical codes: SBS procedure claims — Procedures on musculoskeletal system per Saudi CHI protocol:
Billed procedures: 47385-00-01:Closed rdctn fx shaft radius w/ dis; 90582-00-01:Suture ligmt NEC uni; 90578-00-02:Procurement tendon for graft bil; 47582-00-02:Patellectomy w/ reattachment tend
Documentation: ... | {"denial_codes":["CV4-7"],"icd10":["F05","F03","F05.0"],"sbs":["47385-00-01","90582-00-01","90578-00-02"],"sfda":["2702256953","2401233158","0902221710"]} |
predict medical codes: Encounter type consistency per Saudi CHI mandatory coding policy:
− Routine outpatient chronic disease review coded as emergency consultation (83600-00-90) triggers AD1-7
− Service/procedure performed during outpatient visit but billed as inpatient triggers AD1-3
− Specialist procedure (e.g., car... | {"denial_codes":["AD1-7","AD1-3"],"icd10":["I10","E11.9","I50.1"],"sbs":["83600-00-10","83600-00-90"],"sfda":["126-119-22","2606257633","3-152-87"]} |
predict medical codes: Clinical documentation review per Saudi CHI standards:
Inpatient encounter — Internal Medicine department:
Principal diagnosis: Acute ischaemic stroke, left MCA
Primary procedure: appendectomy
Pharmacotherapy: Sertraline 50mg
LOS: 19 days. ICU days: 2.
All diagnoses coded per ICD-10-AM. Procedure... | {"denial_codes": ["SE1-2", "MN1-1", "AD3-8"], "icd10": ["C67.3", "C21"], "sbs": ["45451-01-00"], "sfda": ["1205233637", "1-303-99"]} |
predict medical codes: Medical necessity review — Saudi MOH/CHI guidelines:
Rheumatoid arthritis, seropositive management per Saudi CHI/MOH protocol:
− Gastroenterology consultation with documented clinical assessment
− Procedure: total knee replacement with documented indication
− Medications: Enoxaparin 40mg, Ceftria... | {"denial_codes": ["SE1-10", "CV4-5", "SE1-4"], "icd10": ["R71", "R94.4", "R40.1"], "sbs": ["52420-00-00", "42659-00-01"], "sfda": ["0810234311", "1707245589", "48-370-13"]} |
predict medical codes: Per Saudi MOH clinical protocol review:
Oral antidiabetic escalation per MOH Saudi Diabetes Protocol:
− Metformin 500 mg BD titrated to 1000 mg BD over 4–8 weeks
− Add Sitagliptin 100 mg/day when HbA1c >7.5% on Metformin monotherapy
− SGLT-2 inhibitor (Dapagliflozin 10 mg/day) preferred in patien... | {"denial_codes":["CV4-2","SE1-8","MN1-1"],"icd10":["E11.9","E11.65"],"sbs":["83600-00-10"],"sfda":["2606257633","7-5518-22","0602256841"]} |
predict medical codes: Discharge summary coding review — Saudi CHI standards:
Patient admitted under Psychiatry with Pre-eclampsia with severe features.
During hospitalisation:
− chest X-ray performed on day 2
− Medications: Levetiracetam 500mg, Ceftriaxone 1g
− Complications: post-procedural bleeding
All active ... | {"denial_codes": ["SE1-4"], "icd10": ["K31"], "sbs": ["90371-00-00", "73350-02-62", "48400-05-02"], "sfda": ["1401256613", "0707257702", "0203256965"]} |
predict medical codes: Saudi National Cancer Screening Programme Guidelines
APPENDIX B: IMPLEMENTATION CHECKLIST
The following checklist is for facility administrators to track guideline implementation:
[ ] Guideline disseminated to all relevant departments
[ ] Training sessions conducted for clinical staff
[ ... | {"denial_codes": null, "icd10": null, "sbs": null, "sfda": null} |
predict medical codes: ICD-10-AM coding per Saudi CHI classification — EXTERNAL CAUSES OF MORBIDITY AND MORTALITY:
Diagnosis codes: X49.69:Accidental poisoning by and exposure to ; V43.94:Car occupant injured in collision with c; W49.70:Exposure to other and unspecified inanim; V87.64:Person injured in collision betwee... | {"denial_codes":["AD1-3","SE1-10"],"icd10":["X49.69","V43.94","W49.70"],"sbs":["83520-00-10","83500-01-00","83510-00-00"],"sfda":["0907245526","2406210832","265-149-02"]} |
predict medical codes: Discharge summary coding review — Saudi CHI standards:
Patient admitted under Neurology with Type 2 diabetes mellitus with complications.
During hospitalisation:
− MRI brain performed on day 3
− Medications: Pantoprazole 40mg, Salbutamol 100mcg MDI
− Complications: medication adverse reacti... | {"denial_codes": ["AD3-5", "SE1-1", "SE1-10"], "icd10": ["N45.0", "N92.3", "N82.3"], "sbs": ["90043-00-00", "18266-02-02"], "sfda": ["2107222326", "2305245340"]} |
predict medical codes: Diagnosis inconsistent with clinical specialty per CHI mandatory policy:
The primary diagnosis does not align with the submitting provider's specialty. Cross-specialty claims require referral documentation. Missing triggers AD1-2. | {"denial_codes":["AD1-2"],"icd10":["X43.43","X44.81","W85.60"],"sbs":["73050-07-50"],"sfda":["1708233994","63-6-94"]} |
predict medical codes: Medical necessity review — Saudi MOH/CHI guidelines:
Sepsis due to E. coli bacteraemia management per Saudi CHI/MOH protocol:
− Psychiatry consultation with documented clinical assessment
− Procedure: MRI brain with documented indication
− Medications: Levetiracetam 500mg, Atorvastatin 40mg
− Cla... | {"denial_codes": ["CV1-5"], "icd10": ["O23.5", "O74"], "sbs": ["97716-00-00", "45530-02-02", "73400-03-80"], "sfda": ["1510246051"]} |
predict medical codes: Mortality and morbidity review — retrospective case discussion:
Case presented at departmental M&M conference on 2022-07-10.
Patient: 48-year-old female admitted with acute stroke.
Timeline of events reviewed. Root cause analysis: delay in escalation identified — action plan created.
This is a re... | {"denial_codes": null, "icd10": ["H57.0"], "sbs": null, "sfda": null} |
predict medical codes: Hospital-acquired pneumonia per Saudi CHI infection protocol:
− HAP onset ≥48 hours post-admission; VAP ≥48–72 hours post-intubation
− Empirical: Piperacillin-Tazobactam 4.5 g IV q8h + Ciprofloxacin 400 mg IV q12h
− MRSA risk: add Vancomycin
− De-escalation mandatory within 48–72 hours based on c... | {"denial_codes":["SE1-6"],"icd10":["J18.0","J15.5","J96.0"],"sbs":["83000-00-02","13882-00-00"],"sfda":["3001233194","2608245825","0409222581"]} |
predict medical codes: ICD-10-AM coding per Saudi CHI classification — DISEASES OF THE RESPIRATORY SYSTEM:
Diagnosis codes: J85:Abscess of lung and mediastinum; J95.1:Acute pulmonary insufficiency following ; J15.2:Pneumonia due to staphylococcus; J98.6:Disorders of diaphragm; J63.0:Aluminosis (of lung)
Principal diagn... | {"denial_codes":["SE1-8","SE1-6","MN1-1"],"icd10":["J85","J95.1","J15.2"],"sbs":["41861-00-00","41879-01-00","41889-01-01"],"sfda":["2301221622","1404245160","0701256533"]} |
predict medical codes: Provider suspension notice:
Claims from provider #70410 are suspended pending investigation into billing irregularities flagged by the CHI fraud detection system. All claims from 2024-10-14 to 2022-06-04 are held. Clinical validity of individual claims is not assessed during suspension. | {"denial_codes": ["SE1-6", "AD3-7"], "icd10": null, "sbs": null, "sfda": null} |
predict medical codes: Discharge summary coding review — Saudi CHI standards:
Patient admitted under Oncology with Community-acquired pneumonia.
During hospitalisation:
− total knee replacement performed on day 4
− Medications: Amlodipine 5mg, Ceftriaxone 1g
− Complications: none documented
All active diagnoses c... | {"denial_codes": ["SE1-3", "SE1-9", "SE1-6"], "icd10": ["P25.8", "P01.0"], "sbs": ["83600-01-81"], "sfda": ["0601268873", "0207257674", "0105233576"]} |
predict medical codes: Laboratory and pathology claim per Saudi CHI standards:
Billed SBS codes:
− 73050-59-10: Detection test other infec agent ; direct probe
− 73050-24-70: Osmolarity ; Tear microfluid
− 73300-01-60: Lidocaine; Quant.
− 73300-02-80: Sirolimus; Quant.
Documentation: clinical indication, reques... | {"denial_codes":["MN1-1"],"icd10":["V28.90","W70.51"],"sbs":["73050-59-10","73050-24-70","73300-01-60"],"sfda":["12-178-13","0709211014"]} |
predict medical codes: CHI mandatory policy audit finding:
Claim audit for Orthopaedics encounter:
− Patient diagnosed with Diabetic ketoacidosis
− laparoscopic cholecystectomy performed and billed
− Prescribed: Aspirin 81mg
− Audit finding: CV1-3 — incomplete documentation
− Corrective action required before claim res... | {"denial_codes": ["CV1-3"], "icd10": ["X45.92", "X35.2", "X49.8"], "sbs": ["37004-03-00", "45797-04-00"], "sfda": ["1511211323", "1106233780"]} |
predict medical codes: SBS procedure claims — Procedures on cardiovascular system per Saudi CHI protocol:
Billed procedures: 38473-00-00:Ins perm epicardial elec pcmkr sbx ; 33836-00-00:Repair coeliac artery dir anstms; 38290-02-00:Opn abltn arhytm crct bth atrl cham; 34103-02-02:Explor iliac art bil
Documentation: p... | {"denial_codes":["SE1-8"],"icd10":["A02.9","A01.4","A00.0"],"sbs":["38473-00-00","33836-00-00","38290-02-00"],"sfda":["18-631-24","2410222783","2008234002"]} |
predict medical codes: Insurance claim submitted for clinical scenario:
Department: Gastroenterology
Diagnosis: Chronic kidney disease stage 4
Procedure: chest X-ray
Medications: Ciprofloxacin 500mg, Levetiracetam 500mg
Documentation reviewed per CHI mandatory policy.
Prior authorization: expired — resubmission require... | {"denial_codes": ["CV4-5", "AD1-4"], "icd10": ["O01.0"], "sbs": ["47564-01-01"], "sfda": ["2708245830", "27-993-20", "2211200280"]} |
predict medical codes: Insurance claim submitted for clinical scenario:
Department: Internal Medicine
Diagnosis: Rheumatoid arthritis, seropositive
Procedure: laparoscopic cholecystectomy
Medications: Sertraline 50mg, Morphine 10mg, Enoxaparin 40mg
Documentation reviewed per CHI mandatory policy.
Prior authorization: p... | {"denial_codes": ["AD1-2"], "icd10": ["K64.1"], "sbs": ["41536-00-02"], "sfda": ["1501256654", "2803233431"]} |
predict medical codes: Discharge summary coding review — Saudi CHI standards:
Patient admitted under Ophthalmology with Rheumatoid arthritis, seropositive.
During hospitalisation:
− bronchoscopy performed on day 4
− Medications: Meropenem 1g
− Complications: medication adverse reaction
All active diagnoses coded.... | {"denial_codes": ["AD1-1"], "icd10": ["T04.9"], "sbs": ["30096-00-00"], "sfda": ["1111200261", "1210234328", "0112222955"]} |
predict medical codes: Accidental fall and non-transport injury coding per Saudi CHI standards:
External cause codes for this episode:
− W12.81: Fall on and from scaffolding, other specified places, while engaged in
− W92.62: Exposure to excessive heat of man-made origin, industrial and construc
− W29.60: Contact... | {"denial_codes":["SE1-4","SE1-8","MN1-1"],"icd10":["W12.81","W92.62","W29.60"],"sbs":["83600-00-90","83600-02-60","40342-00-00"],"sfda":["0409245859","1512200340"]} |
predict medical codes: Discharge summary coding review — Saudi CHI standards:
Patient admitted under Obstetrics with Chronic kidney disease stage 4.
During hospitalisation:
− bronchoscopy performed on day 2
− Medications: Morphine 10mg, Sertraline 50mg
− Complications: hospital-acquired infection
All active diagn... | {"denial_codes": ["SE1-1"], "icd10": ["V50.6", "V16.53", "V69.41"], "sbs": ["45605-00-01", "73300-01-51", "11235-00-10"], "sfda": ["3107245711"]} |
predict medical codes: Palliative care symptom management per Saudi MOH End-of-Life Protocol:
− Dyspnoea: Morphine 2.5–5 mg SC q4h PRN; low-dose benzodiazepine for anxiety
− Nausea: Haloperidol 1.5–3 mg SC BD or Ondansetron 8 mg SC TDS
− Pain breakthrough: 1/6 of total daily opioid as breakthrough dose
− Death rattle: ... | {"denial_codes":["MN1-2","SE1-8"],"icd10":["Z51.5","J44.9"],"sbs":["83600-00-20","83600-02-60"],"sfda":["127-119-22","0802233223"]} |
predict medical codes: Saudi Hypertension Clinical Practice Guideline
DOCUMENT REVISION HISTORY
Version | Date | Change Description | Approved By
--------------------------------------------------------------------------------
Version 1.0 | 2020-07-24 | Initial publication | Approved by: CHI Medical Review Boar... | {"denial_codes": null, "icd10": null, "sbs": null, "sfda": null} |
predict medical codes: Discharge summary coding review — Saudi CHI standards:
Patient admitted under Ophthalmology with Chronic kidney disease stage 4.
During hospitalisation:
− bronchoscopy performed on day 1
− Medications: Sertraline 50mg, Morphine 10mg
− Complications: none documented
All active diagnoses code... | {"denial_codes": ["AD3-5", "SE1-4", "AD3-7"], "icd10": ["D68.2"], "sbs": ["38448-01-00", "49118-00-01"], "sfda": ["2111246309"]} |
predict medical codes: Clinical documentation review per Saudi CHI standards:
Inpatient encounter — Dermatology department:
Principal diagnosis: Pre-eclampsia with severe features
Primary procedure: hernia repair
Pharmacotherapy: Bisoprolol 5mg
LOS: 13 days. ICU days: 3.
All diagnoses coded per ICD-10-AM. Procedures co... | {"denial_codes": ["SE1-5"], "icd10": ["K60.5", "K29.4", "K86.3"], "sbs": ["73050-09-10", "15351-00-01"], "sfda": ["1601256675", "2910246125"]} |
predict medical codes: Male genitourinary procedure claim per Saudi CHI urology protocol:
Billed SBS codes:
− 37605-00-01: Percut aspiration epididymis uni
− 30644-06-02: Bx spermatic cord/epididymis/vas def bil
− 37212-00-00: Open biopsy of prostate or sem ves
− 30641-01-00: Orchidectomy bilateral
Documenta... | {"denial_codes":["SE1-6"],"icd10":["M62.20","W73.14","R03.1"],"sbs":["37605-00-01","30644-06-02","37212-00-00"],"sfda":["0701210397","2601233178","2602256945"]} |
predict medical codes: Radiology report interpretation — no procedure performed by referring clinician:
CT scan of cervical spine reviewed by Psychiatry consultant.
Findings: findings suggestive of underlying condition — correlation with clinical history recommended.
Impression documented. No procedure performed during... | {"denial_codes": null, "icd10": ["S06.23", "S93", "S58"], "sbs": null, "sfda": null} |
predict medical codes: Insurance claim submitted for clinical scenario:
Department: Nephrology
Diagnosis: Acute ischaemic stroke, left MCA
Procedure: MRI brain
Medications: Omeprazole 20mg, Ceftriaxone 1g, Amlodipine 5mg
Documentation reviewed per CHI mandatory policy.
Prior authorization: verified
Potential denial tri... | {"denial_codes": ["AD3-5", "SE1-4"], "icd10": ["K80.2"], "sbs": ["45568-00-00", "90555-00-02"], "sfda": ["16-137-94"]} |
predict medical codes: Insurance claim submitted for clinical scenario:
Department: Internal Medicine
Diagnosis: Osteoporotic vertebral fracture
Procedure: CT abdomen with contrast
Medications: Vancomycin 1g, Ceftriaxone 1g, Insulin Glargine 100IU/mL
Documentation reviewed per CHI mandatory policy.
Prior authorization:... | {"denial_codes": ["SE1-6", "SE1-9", "AD3-7"], "icd10": ["F06.1", "F15.51", "F16.09"], "sbs": ["90901-02-10"], "sfda": ["2004257250"]} |
predict medical codes: Discharge summary coding review — Saudi CHI standards:
Patient admitted under Psychiatry with Acute cholecystitis with cholelithiasis.
During hospitalisation:
− caesarean section performed on day 2
− Medications: Dexamethasone 4mg, Morphine 10mg
− Complications: medication adverse reaction
... | {"denial_codes": ["AD1-4"], "icd10": ["O91.11"], "sbs": ["98004-00-12", "41905-08-02", "73050-59-60"], "sfda": ["2509258265"]} |
predict medical codes: Saudi Heart Failure Management Guideline
REFERENCES
1. Dr. Abdullah Al-Mutairi, Dr. Reem Al-Tamimi, Dr. Bander Al-Otaibi, et al.. Adherence to clinical practice guidelines in emergency departments: a cross-sectional study. Saudi Medical Journal. 2019;1(10):52–68. doi:10.9829/jfcm.2018.7491
... | {"denial_codes": null, "icd10": null, "sbs": null, "sfda": null} |
predict medical codes: Outpatient consultation — initial assessment:
Patient referred by GP for evaluation. Chief complaint: progressive shortness of breath on exertion.
History of present illness documented. Past medical history reviewed. Family history notable for no significant family history.
Physical examination c... | {"denial_codes": null, "icd10": ["S14.2", "S42.10", "S00.8"], "sbs": null, "sfda": null} |
predict medical codes: Discharge summary coding review — Saudi CHI standards:
Patient admitted under Obstetrics with Deep vein thrombosis, left leg.
During hospitalisation:
− bone marrow biopsy performed on day 3
− Medications: Insulin Glargine 100IU/mL, Atorvastatin 40mg
− Complications: post-procedural bleeding... | {"denial_codes": ["CV1-4", "SE1-2", "SE1-7"], "icd10": ["O36.4", "O99", "O24.49"], "sbs": ["30644-03-02", "90218-00-00"], "sfda": ["3005222089"]} |
predict medical codes: DVT and PE treatment per Saudi MOH anticoagulation protocol:
− DVT: Rivaroxaban 15 mg BD × 3 weeks then 20 mg OD
− Massive PE: systemic thrombolysis (Alteplase 100 mg over 2 hours)
− Extended anticoagulation for unprovoked VTE, cancer-associated VTE, recurrent events
− LMWH (Enoxaparin 1 mg/kg SC... | {"denial_codes":["SE1-6","SE1-8"],"icd10":["I26.9","I26.0"],"sbs":["83600-00-90","83000-00-02"],"sfda":["54-4-13","23-883-19","0211234420"]} |
predict medical codes: Radiology report interpretation — no procedure performed by referring clinician:
CT scan of chest reviewed by Paediatrics consultant.
Findings: no acute abnormality identified.
Impression documented. No procedure performed during this encounter. No medications prescribed.
Recommendation: clinical... | {"denial_codes": null, "icd10": ["T42.1"], "sbs": null, "sfda": null} |
predict medical codes: Discharge summary coding review — Saudi CHI standards:
Patient admitted under Dermatology with Acute cholecystitis with cholelithiasis.
During hospitalisation:
− echocardiography performed on day 5
− Medications: Warfarin 5mg, Enoxaparin 40mg, Bisoprolol 5mg
− Complications: none documented... | {"denial_codes": ["SE1-8", "AD1-3"], "icd10": ["K44.0", "K41.9", "K76.7"], "sbs": ["73100-19-50"], "sfda": ["0801256551"]} |
predict medical codes: Clinical documentation review per Saudi CHI standards:
Inpatient encounter — Paediatrics department:
Principal diagnosis: Epilepsy, focal, drug-resistant
Primary procedure: haemodialysis session
Pharmacotherapy: Insulin Glargine 100IU/mL, Furosemide 40mg
LOS: 6 days. ICU days: 0.
All diagnoses co... | {"denial_codes": ["CV1-4", "CV4-6", "CV4-7"], "icd10": ["D75.1", "D02.2", "D57.0"], "sbs": ["90402-01-00", "48400-00-01"], "sfda": ["1301256600", "0202233205", "2305233709"]} |
predict medical codes: Major depressive disorder treatment per Saudi MOH Mental Health Protocol:
− First-line: SSRI (Escitalopram 10–20 mg OD, Sertraline 50–200 mg OD)
− PHQ-9 score documented at baseline and every 4 weeks
− Antidepressant trial minimum 4–6 weeks at therapeutic dose before switching
− Referral to psych... | {"denial_codes":["SE1-8","CV4-1"],"icd10":["F32.1","F32.2","F33.1"],"sbs":["83600-01-70","83600-00-10"],"sfda":["2403257155","0206257519","0701256530"]} |
predict medical codes: Clinical documentation review per Saudi CHI standards:
Inpatient encounter — Nephrology department:
Principal diagnosis: Sepsis due to E. coli bacteraemia
Primary procedure: appendectomy
Pharmacotherapy: Insulin Glargine 100IU/mL, Warfarin 5mg
LOS: 14 days. ICU days: 0.
All diagnoses coded per IC... | {"denial_codes": ["AD1-2", "AD3-7", "SE1-6"], "icd10": ["H60.4", "H50.0", "H35.9"], "sbs": ["47327-00-02"], "sfda": ["0403256978"]} |
predict medical codes: Per Saudi MOH clinical protocol review:
Gender-procedure inconsistency per Saudi CHI coding validation:
− A patient registered as female in the insurance system was billed for prostate biopsy (37219-00-00) and PSA screening.
− Cross-referencing HIS records confirmed the patient is male — a regist... | {"denial_codes":["AD3-8","AD3-6","SE1-7"],"icd10":["C61","Z12.5"],"sbs":["83600-00-20"],"sfda":["none"]} |
predict medical codes: Medical necessity review — Saudi MOH/CHI guidelines:
Acute ischaemic stroke, left MCA management per Saudi CHI/MOH protocol:
− Psychiatry consultation with documented clinical assessment
− Procedure: percutaneous coronary intervention with documented indication
− Medications: Metformin 1000mg, As... | {"denial_codes": ["SE1-4", "AD1-1", "SE1-8"], "icd10": ["P58.9"], "sbs": ["45448-00-02", "73200-03-00", "46405-00-02"], "sfda": ["1311246214", "2711222940", "222-149-01"]} |
predict medical codes: MOH Maternal and Neonatal Health Clinical Pathway
COPYRIGHT AND DISCLAIMER
© 2023 Council of Health Insurance, Kingdom of Saudi Arabia. All rights reserved.
This document may be freely reproduced for educational and non-commercial purposes with appropriate citation. Commercial use requires wri... | {"denial_codes": null, "icd10": null, "sbs": null, "sfda": null} |
predict medical codes: CHI mandatory policy audit finding:
Claim audit for Psychiatry encounter:
− Patient diagnosed with Community-acquired pneumonia
− upper GI endoscopy performed and billed
− Prescribed: Amlodipine 5mg
− Audit finding: CV1-3 — incomplete documentation
− Corrective action required before claim resubm... | {"denial_codes": ["CV1-3", "AD1-4"], "icd10": ["B90.9", "B30.8"], "sbs": ["73050-00-00", "73100-21-70"], "sfda": ["21-346-07", "0412258727", "1111200262"]} |
predict medical codes: Insurance claim — compliant submission per CHI standards:
Department: Dermatology
Diagnosis: Acute exacerbation of COPD, GOLD stage III
Treatment: Bisoprolol 5mg, Levetiracetam 500mg, Morphine 10mg
All documentation complete. Prior authorization verified. SFDA registration confirmed.
Diagnosis-pr... | {"denial_codes": null, "icd10": ["I97.39"], "sbs": ["30615-00-00"], "sfda": ["2501221640", "2510211234"]} |
predict medical codes: Stroke prevention in AF per Saudi CHI/MOH protocol:
− Anticoagulation indicated for CHA₂DS₂-VASc ≥2 (men) or ≥3 (women)
− DOACs (Rivaroxaban 20 mg OD, Apixaban 5 mg BD) preferred over Warfarin for non-valvular AF
− Warfarin (INR 2.0–3.0) for AF with mechanical valves or mitral stenosis
− CHA₂DS₂-... | {"denial_codes":["MN1-1","CV4-1","SE1-8"],"icd10":["I48.0","I48.1","I48.9"],"sbs":["83600-00-10","83600-00-20"],"sfda":["54-4-13","0211234420","1-5550-20"]} |
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