Blood gas analysis is one of the widely used testing items in clinical practice, effectively assisting doctors in studying the condition, differential diagnosis, monitoring treatment efficacy, and postoperative evaluation.
Blood gas analysis is a method that uses a blood gas analyzer to measure the H+ concentration in human blood and the gases dissolved in the blood (mainly CO2 and O2) as well as electrolytes, to understand the respiratory function and acid-base balance of the human body. It can directly reflect lung ventilation function, acid-base balance, and electrolyte status.
In recent years, the development of blood gas analyzers has made significant progress, allowing clinical laboratories to conveniently, accurately, and quickly perform blood gas analysis. Some companies have launched blood gas analyzers that integrate all electrodes, calibration gases, calibration waves, waste liquid bags, etc., into a disposable analysis package. Once the analysis package is used up, these components are discarded, eliminating the need to replace any components in between. Therefore, no special maintenance measures are required, reducing the inconvenience caused by maintenance for operators.
1IndicationsDiagnosis of hypoxemia and respiratory failure; differential diagnosis of dyspnea; differential diagnosis of coma; selection of surgical indications; application, adjustment, and weaning of ventilators; monitoring of respiratory therapy; diagnosis of acid-base imbalance, etc.2Sampling RequirementsClinically, samples can be divided into arterial blood, venous blood, and mixed venous blood, among other types. Although blood gas analysis can be performed using various blood samples, arterial blood is most commonly used. In emergencies, venous blood can be used as a substitute for arterial blood, and in special cases, arterialized capillary sampling can be used (such as from the finger, earlobe, heel, etc.); many experts now compare arterial and venous blood in clinical practice to assess whether the body is hypoxic at an early stage.3Detection IndicatorsThe blood gas analyzer can detect the concentration of various substances in the blood, among which the three most representative indicators are pH, PO2, and PCO2, and it can calculate a series of parameters, with detection items exceeding 50, making it a complex and comprehensive project.(1) Main Indicators of Blood Gas and Acid-Base Analysis in the “National Clinical Laboratory Operation Procedures (4th Edition)”1. Blood Oxygen Analysis:Blood oxygen analysis generally includes the following measured parameters: oxygen partial pressure, oxygen saturation, and oxygen partial pressure at 50% hemoglobin oxygen saturation, deoxyhemoglobin or reduced hemoglobin, oxyhemoglobin, and carboxyhemoglobin.2. Acid-Base Level:The acid-base level of blood is the negative logarithm of [H+], and [HCO3-]/[H2CO3-] is the main factor determining blood pH.3. Carbon Dioxide Partial Pressure:Carbon dioxide partial pressure [PCO2] refers to the pressure of physically dissolved [CO2] in plasma. [PCO2] represents the respiratory factor in acid-base imbalance, and its change can directly affect the change in blood pH.4. Total Carbon Dioxide:Total carbon dioxide [TCO2] is the sum of various forms of [CO2] present in plasma. [TCO2] is influenced by both respiratory and metabolic factors in the body, but is mainly affected by metabolic factors.5. Actual Bicarbonate and Standard Bicarbonate:Actual bicarbonate [AB] refers to the actual content of [HCO3-] in human plasma, which is an important indicator of metabolic acid-base imbalance and is also influenced by respiratory factors. Standard bicarbonate [SB] refers to the [HCO3-] content at a temperature of 37°C, [PCO2] of 5.32 kPa (40 mmHg), and [SatO2] of 100%, excluding the influence of respiratory factors.6. Base Excess:Base excess (BE) refers to the amount of acid or base needed to adjust the pH of 1L of blood to 7.40 under standard conditions, i.e., at a temperature of 37°C, a standard atmospheric pressure, [PCO2] of 5.32 kPa (40 mmHg), and [SatO2] of 100%. The BE value in normal individuals fluctuates around 0.7. Anion Gap:The anion gap [AG] refers to the difference between the concentration of unmeasured anions [UA] and unmeasured cations [UC] in plasma, i.e., AG = UA – UC. This value can be calculated based on the routinely measurable cations [Na+, K+] and the routinely measured anions [Cl-, HCO3-]. That is, AG = [Na+, K+] – [Cl-] + [HCO3-].8. Buffer Base:Buffer base [BB] is the total of the bases in the blood that have buffering action, including [HCO3-], [HPO4-], hemoglobin, and plasma proteins. BB reflects the overall buffering capacity of the body in response to acid-base balance disturbances and is not affected by respiratory factors and changes in carbon dioxide.(2) Main Indicators for Monitoring Blood Gas Analysis in Clinical Diagnosis and Treatment NormsAccording to the “Clinical Technical Operation Norms – Critical Care Medicine Volume” compiled by the Chinese Medical Association (Document No. 73 issued by the Health Bureau in 2002), the main indicators for determining blood gas analysis results are: pH, PaCO2, SaO2, PaO2, standard HCO3-, base excess, etc.(3) Main Items in the Basic Medical Service Price DirectoryThe basic medical service price directory classifies blood gas analysis under clinical diagnosis and treatment items with the initial code of 31, which includes “blood pH, blood oxygen, and blood carbon dioxide measurement as well as acid-base balance analysis.”
From the perspective of operational norms, clinical diagnosis and treatment, and price charging, the indicators of potassium ions, sodium ions, chloride ions, bicarbonate, etc., in blood gas analysis are intermediate values in acid-base balance analysis and are essential steps in conducting blood gas analysis, and should not be charged separately.
4Qualifications for Blood Gas Analysis Testing and Reporting (Only for ICU and Anesthesia Departments, with ICU as an example)Different departments have different views on this issue. Some believe that blood gas analysis must be performed by the laboratory department and relevant reports issued; others argue that since the coding for blood gas analysis in the diagnosis and treatment directory starts with 31, which belongs to clinical diagnosis and treatment, it does not necessarily have to be performed by the laboratory department, and clinical departments can also conduct tests and issue reports.From the perspective of coding classification in the diagnosis and treatment directory, items starting with code 25 generally belong to projects that can only be conducted and reported by the laboratory department; however, items starting with code 31, which are clinical diagnosis and treatment projects, are not necessarily exclusively conducted and completed by clinical departments. For example, EEG, EMG, potassium load tests, etc., also belong to projects starting with code 31, which involve both laboratory and other auxiliary departments, so their classification cannot serve as the basis for determining testing qualifications.(1) The Critical Care Medicine Department Can Conduct Blood Gas AnalysisCurrently, the clinical department that performs the most blood gas analysis is the ICU and other critical care departments. Do they have the qualifications to directly conduct tests and issue reports? The “Guidelines for the Construction and Management of Critical Care Medicine” (2020 Edition) requires: “The ICU should be equipped with ECG machines, blood gas analyzers, defibrillators, blood purification devices, continuous hemodynamic monitoring equipment, cardiopulmonary resuscitation emergency equipment (which includes laryngoscopes, tracheal tubes, various connectors, emergency drugs, and other rescue tools), ultrasound diagnostic devices, temporary external pacemakers, bronchoscopes, and cleaning and disinfection equipment, physical sputum clearance devices, electronic temperature control devices, and pneumatic compression pumps for thrombosis prevention, etc.; the specific quantity should be determined based on clinical needs.” The bedside rapid blood gas analyzer shortens the time for emergency testing and reporting, with reporting times reduced to just a few minutes, allowing emergency doctors to obtain clinical test results promptly, facilitating quick decision-making and intervention, and ensuring timely treatment for critically ill patients, thereby improving early diagnosis rates.In other words, the ICU can directly use bedside rapid blood gas analyzers to conduct blood gas analysis.(2) Conditions for Critical Care Medicine Physicians to Conduct Blood Gas AnalysisWhen ICU physicians conduct bedside rapid blood gas analysis, the following conditions must be met:1. The ICU ward must be equipped with bedside rapid blood gas analyzers, allowing for immediate testing and analysis to monitor changes in the patient’s condition;2. ICU physicians must undergo specialized training (usually provided by the manufacturer for specific blood gas analyzers or organized by health organizations or the hospital’s medical department), and after training and passing assessments, the medical department can authorize the qualification certificate for all ICU physicians;3. The blood gas analysis results must be signed by the operating physician and attached to the medical record;4. Gradually, the bedside blood gas analyzers in the ICU should be integrated with the hospital’s LIS system, synchronizing the results after testing and storing them in the LIS system for unified management, allowing physicians to access and query the results in electronic medical records at any time, and enabling patients and their families to view blood gas results through the WeChat service account – Mobile Hospital.(3) Conducting Blood Gas Analysis in Non-Critical Care Departments is a ViolationNote:Direct blood sampling for blood gas analysis testing in departments other than critical care medicine violates the “Management Measures for Clinical Laboratories in Medical Institutions” (Document No. 73 issued by the Health Bureau in 2006), which states: “Article 9: Clinical laboratories in medical institutions should be centrally set up, uniformly managed, and share resources.” “Article 10: Medical institutions should ensure that clinical laboratories have professional technical personnel, venues, facilities, and equipment that are compatible with their clinical testing work.” “Article 21: Non-clinical laboratories must not issue clinical test reports to clinical departments and must not charge corresponding testing fees.” This constitutes a violation of qualifications and illegal charging.From the use of POCT (point-of-care testing) instruments in clinical departments, it does not comply with the above provisions of the Health Bureau Document No. 73 of 2006, and is strictly speaking, illegal. Although the laboratory department is at a disadvantage in the competition for POCT with clinical departments, there is policy support.(4) Testing Items Outside the Main Indicators of Blood Gas Analysis Should Not Be Charged SeparatelyAccording to the “National Clinical Laboratory Operation Procedures (4th Edition)” and the “Clinical Technical Operation Norms – Critical Care Medicine Volume” (Document No. 73 issued by the Health Bureau in 2002), combined with the medical service price management directory, the connotation of blood gas analysis is described as “including blood pH, blood oxygen, and blood carbon dioxide measurement as well as acid-base balance analysis.”Although the critical care medicine department can detect dozens of items during blood gas analysis, only blood pH, blood oxygen, blood carbon dioxide measurement, and acid-base balance analysis fall within the qualifications and charging scope of critical care medicine physicians, and these items belong to the content of blood gas analysis and cannot be charged separately.
Critical care medicine physicians conducting blood gas analysis POCT can only be responsible for the above indicators and can sign on the report. Other testing items fall under the management scope of the laboratory department and cannot issue test reports or charge separately.
5Common Issues and Analysis of Medical Insurance Violations in Blood Gas AnalysisAccording to the regulations of the diagnosis and treatment directory, the connotation of blood gas analysis is generally described as “including blood pH, blood oxygen, and blood carbon dioxide measurement as well as acid-base balance analysis”;the pricing unit is “per test,” with prices around 50 yuan.However, in many provinces, the connotation of blood gas analysis is empty, and it can refer to the connotation of the “National Medical Service Price Project Specification 2012 Edition,” which states: “Sample type: blood. Sample collection, receipt, processing, calibration, and quality control, testing samples (including arterial blood oxygen partial pressure, alveolar-arterial oxygen partial pressure difference, arterial blood oxygen saturation, mixed venous blood oxygen partial pressure, arterial blood oxygen content, arterial blood carbon dioxide partial pressure, pH value, standard bicarbonate, actual bicarbonate, buffer base, excess base, plasma carbon dioxide content, anion gap), reviewing results, entering laboratory information systems or manual registration, sending reports; handling waste according to regulations; accepting clinical-related consultations.” The clearly defined items in the connotation cannot be charged separately.(1) Charging for Serum Bicarbonate (HCO3) Measurement Along with Blood Gas Analysis is Decomposed ChargingThe connotation of the blood gas analysis project includes acid-base balance analysis, and according to the “Clinical Technical Operation Norms – Critical Care Medicine Volume” (Document No. 73 issued by the Health Bureau in 2002), Chapter 2, Section 10, HCO3 is an important component indicator of acid-base balance, which belongs to decomposed charging.(2) Charging for Blood Oxygen Saturation Monitoring Along with Blood Gas Analysis is Decomposed and Interchange ChargingThe connotation of the blood gas analysis project includes blood oxygen measurement, which includes blood oxygen saturation measurement. If charged separately, it constitutes decomposed charging violations.(3) Charging for Hematocrit Along with Blood Gas Analysis is Excessive Testing ViolationSome blood gas analyzers can provide hematocrit detection indicators. Can this be charged separately? Since all patients undergo routine blood tests upon admission, blood cell analysis (sometimes referred to as routine blood tests with five classifications, etc.) already includes the hematocrit project, charging for hematocrit during blood gas analysis constitutes repeated or excessive testing violations. Additionally, specialized testing will only be conducted if hematocrit is abnormal or there are clinical indications.(4) Charging for Electrolytes K+, Na+, Cl-, etc., Along with Blood Gas Analysis is a ViolationFrom the perspective of operational norms, clinical diagnosis and treatment, and price charging, the indicators of potassium ions, sodium ions, chloride ions, bicarbonate, etc., in blood gas analysis are intermediate values in acid-base balance analysis and are essential steps in conducting blood gas analysis, and should not be charged separately.(5) Charging for Lactate Measurement Along with Blood Gas Analysis is a ViolationCurrently, blood gas analyzers can measure more and more items, not only directly measuring pH, oxygen partial pressure, and carbon dioxide partial pressure, as well as standard bicarbonate, base excess, and buffer base, but also calculating related indicators (such as SO2, actual bicarbonate, etc.), and can detect various electrolytes and metabolic levels, including glucose, lactate, blood urea nitrogen (BUN), and creatinine.Does this mean that any item that the blood gas analyzer can detect can be charged separately? Can lactate measurement be charged multiple times on the same day of blood gas analysis?1. Does Acid-Base Balance Include Lactate?The “National Medical Service Price Project Specification 2012 Edition” and other provincial regulations regarding the connotation of blood gas analysis are basically the same, stating “including blood pH, blood oxygen, and blood carbon dioxide measurement as well as acid-base balance analysis.” Under normal circumstances, the indicators for acid-base balance analysis do not include lactate, meaning that lactate measurement is not a mandatory indicator for acid-base balance assessment. How should lactate measurement be charged reasonably after the blood gas analysis results are obtained?2. Standard Operating Procedures for Lactate Measurement Charging.The “National Medical Service Price Project Specification 2012 Edition” states that the connotation of lactate measurement includes “sample types: blood, cerebrospinal fluid, gastric fluid. Sample collection, receipt, processing, calibration, and quality control, testing samples, reviewing results, communicating with clinical staff based on actual conditions, entering laboratory information systems or manual registration, sending reports; making notes for special situations, providing clinical suggestions; handling waste according to regulations; accepting consultations or consultations.” The “National Clinical Laboratory Operation Procedures (4th Edition)” (People’s Health Publishing House, 2015 Edition) clearly states that “lactate measurement can be performed using enzyme-catalyzed methods, chemical oxidation methods, electrochemical methods, and enzyme electrode sensors. The latter three are chemical methods. Chemical methods are complex and influenced by many factors, while enzyme-catalyzed methods have high sensitivity, wide linear range, and are suitable for automated analyzers, making them the ideal common method for lactate measurement.” “The type of specimen anticoagulant should be heparin-fluoride, and plasma should be separated as soon as possible. Since potassium oxalate has a certain inhibitory effect on lactate dehydrogenase, it should not be chosen as an anticoagulant.” In summary, specific specimen collection, specific testing reagents, specific testing methods or specific testing instruments, and specialized laboratory departments sending reports and signing are required.3. Violations of Charging for Lactate Measurement Along with Blood Gas Analysis.From the above, it can be seen that if lactate measurement is conducted separately by the laboratory department on the same day as blood gas analysis, and if the report is sent separately and the charging quantity does not exceed 2 times, it is generally not considered a violation. Although lactate measurement is not an indicator of acid-base balance in blood gas analysis, it can be conducted separately based on clinical needs.(1) Conducting lactate measurement on the same specimen, at the same time, and with the same instrument as blood gas analysis constitutes interchange charging or non-standard testing charging. That is, lactate measurement conducted by the blood gas analyzer is often performed using ion electrode methods, which differ from the measurement methods required by the “National Clinical Laboratory Operation Procedures (4th Edition)” and do not conform to the connotation and requirements of the lactate measurement project in the diagnosis and treatment directory, constituting a violation of interchange charging.(2) Conducting lactate measurement by non-laboratory departments constitutes non-standard or unqualified charging. According to the connotation of the diagnosis and treatment directory, lactate measurement is a laboratory testing project, and other departments must not conduct it, violating the “Management Measures for Clinical Laboratories in Medical Institutions” (Document No. 73 issued by the Health Bureau in 2006).(6) Issues with Blood Gas Analysis Pricing and Reagent CostsThe unit price for blood gas analysis is generally around 50 yuan, while the cost of blood gas analysis reagents in some hospitals is around 60 yuan, leading to a “cost inversion” between blood gas analysis testing fees and reagent costs. Therefore, charging separately for electrolytes involved in acid-base balance analysis leads to repeated charging, resulting in more violations, and under the DRG/DIP payment reform, this is highly discouraged.Regarding the “cost inversion” between testing fees and reagent costs, a low pricing structure is not a reason for illegal charging under the current pricing system. With the continuous advancement of national centralized procurement policies, it is believed that reagent costs will continue to decrease, and hospitals can engage in alliance procurement or negotiate to lower procurement costs.
Analysis of Controversies
1. The technical specifications of the project cannot simply equate to the connotation of project charging;
2. If electrolytes involved in blood gas analysis cannot be charged, can clinical departments refrain from providing electrolyte values;
3. Currently, the pricing of blood gas analysis projects does not cover costs; why can electrolytes not be charged?
Controversy 1 – The technical specifications of the project cannot simply equate to the connotation of project charging.① In terms of the existing pricing system and price formation, project technical specifications ≠ project connotation, which is very clear. How a medical service project is charged is based on the local medical service price manual.② According to the current medical service price manual in various provinces, the connotation of blood gas analysis projects includes: blood pH, blood oxygen, and blood carbon dioxide measurement as well as acid-base balance analysis.③ According to the medical service price specification usage instructions, “project connotation” uniformly standardizes the facilities, equipment, and technical service content commonly used in the operation process of medical service price projects (including operational processes, main paths, methods, or steps), which is an important reference for price formulation.④ According to the medical service price specification, the explanation of “including”: indicates the service content that should be provided by the project, and these service contents cannot be charged separately. Blood gas analysis includes blood pH, blood oxygen, and blood carbon dioxide measurement as well as acid-base balance analysis, so all included content cannot be charged separately.⑤ According to the “National Clinical Laboratory Operation Procedures (4th Edition)”, blood gas analysis and acid-base balance analysis require the measurement of the following parameters:Blood oxygen analysis (oxygen partial pressure, oxygen saturation, and oxygen partial pressure at 50% hemoglobin oxygen saturation, deoxyhemoglobin or reduced hemoglobin, oxyhemoglobin, and carboxyhemoglobin),acid-base level ([H+] negative logarithm, [HCO3-]/[H2CO3-] is the main factor determining blood pH),carbon dioxide partial pressure,total carbon dioxide,actual bicarbonate, standard bicarbonate,base excess,anion gap (the difference between the concentration of unmeasured anions [UA] and unmeasured cations [UC] in plasma, i.e., AG = UA – UC. This value can be calculated based on the routinely measurable cations [Na+, K+, Ca++] and the routinely measured anions [Cl-, HCO3-]. That is, AG = [Na+, K+, Ca++] – [Cl-] + [HCO3-]),buffer base ([HCO3-], [HPO4-], hemoglobin, plasma proteins).⑥ The basic logic for calculating the cost of medical service projects: the steps necessary to conduct a medical service and the costs involved are generally included in the cost calculation. According to the elements of medical service project price cost calculation, price formation includes basic labor costs (average salary of various personnel in the hospital, project labor cost expenses), basic material consumption (routine consumables), independent consumables used in the project (disposable independent consumables, reusable medical materials), depreciation costs of instruments and equipment, etc.⑦ In summary, the electrolytes involved in acid-base balance analysis included in blood gas analysis are already part of the cost of the blood gas analysis project.Controversy 2 – If electrolytes involved in blood gas analysis cannot be charged, can clinical departments refrain from providing electrolyte values?According to Controversy 1, this controversy becomes simple. The blood gas analysis report can omit electrolyte values, but the AG value must be provided, meaning that regardless of whether the electrolyte values are displayed, testing must be conducted. (If electrolyte values are not provided, they cannot be charged.)Controversy 3 – Currently, the pricing of blood gas analysis projects does not cover costs; why can electrolytes not be charged?The unit price for blood gas analysis is generally around 50 yuan, while the cost of blood gas analysis reagents in some hospitals is around 60 yuan, leading to a “cost inversion” between blood gas analysis testing fees and reagent costs. Under the current pricing system, a low pricing structure is not a reason for illegal charging. With the continuous advancement of national centralized procurement policies, it is believed that reagent costs will continue to decrease, and hospitals can engage in alliance procurement or negotiate to lower procurement costs.Suggestions:
1. Based on actual conditions, re-calculate the costs of blood gas analysis projects to avoid situations where reagent/card costs and blood gas analysis prices lead to “doing one, losing one.”
2. Include consumables involved in blood gas analysis in “centralized procurement” to reduce procurement costs through volume discounts.
3. If the project cost calculation did not consider the electrolyte factors, it is recommended to exclude electrolytes by improving the project connotation.
Disclaimer: The above views represent the author’s personal opinions and are subject to local policies.Source: Medical Insurance Notes
END
Disclaimer: The intellectual property rights of the content published by Aiden Medical Technology are exclusively owned or held by Aiden Medical Technology and related rights holders.The interview data mentioned in the text are provided and confirmed by the interviewees.Unauthorized reproduction, excerpting, copying, or establishing mirrors of any use is prohibited.People who like this content also like:：
[Live Preview] How can hospitals effectively manage medical insurance under the continuous reform of payment methods? The experiences of medical insurance personnel in Hebei are worth learning!
Encoding Audit Log | How to tackle coding difficulties in neurological, digestive, and circulatory system diseases?
The national inspection team strictly checks hospitals! Many places encourage reporting
Aiden Doctors
Doctor Career Advancement Platform
←Click the image to experience immediately
Follow [Aiden Academy] to open the door to online knowledge learning