What is PRO Not Responsible For Reviewing in coding?

PRO (Peer Review Organisation) is not responsible for reviewing the following in coding:

1. Medical Necessity: PROs do not assess whether the medical care or services provided were medically necessary. This determination is typically made by the health insurance plan or the attending physician.

2. Accuracy of Diagnosis: PROs do not verify the accuracy of the diagnosis or the appropriateness of the treatment provided. This is the responsibility of the treating physician and the health insurance plan.

3. Coding Compliance: PROs do not review medical records for coding compliance. Coding is typically done by the healthcare provider's billing department or a third-party coding company.

4. Fraud and Abuse: PROs do not investigate or address issues related to fraud and abuse. These matters are typically handled by law enforcement or the health insurance plan's internal investigations department.

5. Patient Consent: PROs do not assess whether the patient provided informed consent for the care or services received. This is typically the responsibility of the healthcare provider.

6. Provider Qualifications: PROs do not review the qualifications or credentials of the healthcare provider who provided the care or services. This is typically done by the health insurance plan or the state licensing board.

7. Hospital Accreditation: PROs do not assess the accreditation status of the hospital or other healthcare facility where the care or services were provided. This is typically done by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or other accrediting bodies.

However, it's important to note that PROs have specific responsibilities and functions outlined in their contracts with the Centers for Medicare & Medicaid Services (CMS) or other government agencies. These responsibilities may vary based on the specific program or contract.