Review Process. Introduction. Reference materials. InterQual Procedures Criteria
|
|
- Mervin Peter Armstrong
- 5 years ago
- Views:
Transcription
1 InterQual Procedures Criteria Review Process Introduction As part of the InterQual Care Planning family of products, InterQual Procedures Criteria provide healthcare organizations with evidence-based clinical decision support for procedures. Healthcare providers and reviewers use the criteria to make effective utilization decisions at the point of care or during the preauthorization process. Criteria are presented in an interactive question-and-answer (Q&A) format. As you conduct a review, your answers to questions about the patient s clinical presentation will lead you to the recommended procedure(s). The criteria reflect clinical interpretations and analyses and cannot alone either resolve medical ambiguities of particular situations or provide the sole basis for definitive decisions. The criteria are intended solely for use as screening guidelines with respect to the medical appropriateness of health care services and not for final clinical or payment determinations concerning the type or level of medical care provided, or proposed to be provided, to a patient. When conducting reviews, the issue of gender may be relevant. InterQual content contains numerous references to gender. Depending on the context, these references may refer to either genotypic or phenotypic gender. At the individual patient level, a variety of factors, including but not limited to gender identity and gender reassignment via surgery or hormonal manipulation, may affect the applicability of some InterQual criteria. This is most often the case with genetic testing and procedures that assume the presence of gender-specific anatomy. With these considerations in mind, all references to gender in InterQual have been reviewed and modified when appropriate. InterQual users should carefully consider issues related to patient genotype and anatomy, especially for transgender individuals, when appropriate. Reference materials Reference materials are provided with the criteria and should be used to assist in the correct interpretation of the criteria. For example: Bibliographies Clinical revisions Copyright 2018 Change Healthcare LLC and/or one of its subsidiaries. All Rights Reserved. Produced in Cork, Ireland. 1
2 Abbreviations and symbols list Drug list They are available within the software, for example, on the InterQual Review Manager Help menu in the InterQual Clinical Reference. Additionally, Change Healthcare Customer Hub provides: Interactive support Answers to commonly asked questions Bibliographies Clinical revision documents Links to other resources Informational notes Informational notes provide information regarding best clinical practice, new clinical knowledge, explanations of criteria rationale, definitions of medical terminology, and current literature references. The notes in the criteria are specific to each question, answer, and/or recommendation. How to conduct a medical review During a medical review, you use the criteria as a decision support tool to assess the medical appropriateness of a given procedure. Although labeled as a Medical Review in the software, this type of review is also known as a primary review. This first-level review typically involves a non-physician reviewer who uses the criteria to determine if the request is appropriate or if the review requires secondary review. Conduct a medical review as follows: Copyright 2018 Change Healthcare LLC and/or one of its subsidiaries. All Rights Reserved. Produced in Cork, Ireland. 2
3 Step 1: Select a category Select a category. If you are uncertain about which category to select, select All Categories. Categories organize specific, logical clinical groupings of procedures. Procedures Criteria are organized according to the following medical specialty categories: Cardiology Cardiothoracic General Surgery Hand, Plastic & Reconstructive Neurosurgery Obstetrics & Gynecology Ophthalmology Oro-Maxillo-Facial, Dental & Otolaryngology Orthopedic - Lower Extremity Orthopedic - Upper Extremity Podiatry Specialized Procedures Urology Vascular Each medical specialty category contains surgical and invasive procedures generally performed by physicians in that surgical specialty. The Specialized Procedures category contains procedures performed by a variety of surgical and behavioral health specialists. There are also two age-related categories: Adult - patients 18 years of age Pediatric - patients < 18 years of age In some subsets, the content in the Pediatric category is appropriate for adolescents only, which are defined as 13 and < 18 years of age. Step 2: Select a subset Select a subset. You can search for a subset using one or more of the following methods: By category By keyword(s) By medical code(s) Copyright 2018 Change Healthcare LLC and/or one of its subsidiaries. All Rights Reserved. Produced in Cork, Ireland. 3
4 A subset is the procedure that is being reviewed (e.g., appendectomy, colonoscopy, craniotomy). The adult and pediatric content are in separate subsets. Pediatric content includes (Pediatric) in the subset description, e.g., Appendectomy (Pediatric). The subset overview notes include notes regarding alternate procedure names. These notes provide a list of additional names by which the requested intervention may be referred or the names of different procedures that produce the same result. For example, Roux-en-Y Gastric Bypass (RYGB) and Laparoscopic Adjustable Gastric Banding (LAGB) are alternate procedure names found in the Bariatric Surgery criteria subset. They are two different weight loss surgery procedures for patients with obesity. The subset overview notes also include Inpatient/Outpatient designations. These designations may be included with the recommendation to provide an Inpatient or Outpatient setting recommendation. The recommended settings are determined by literature, data, and InterQual consultant consensus and are based on best medical practices. The recommendation of Inpatient refers to those procedures most commonly performed in the acute care setting and for which admission to the hospital is indicated (typically a stay of 24 hours or more). The Outpatient recommendation refers to those procedures performed in the physician s office, in an ambulatory care setting, or procedures that do not require an acute hospital admission (typically a stay of less than 24 hours). Step 3: Complete the review detail information This step applies to InterQual Review Manager users only. Complete the review detail information. Review detail includes information pertinent to the review, for example, requested services, requesting provider(s), facility, service start and end dates, and comments. Step 4: Answer medical review questions Answer the medical review questions based on the clinical scenario. The medical review is a sophisticated, branching-logic algorithm for evidence-based procedures; a series of questions directs you to the most appropriate pathway based on the clinical need for the procedure. For example, in the Bronchoscopy subset, you are presented with a list of medical conditions that may require the procedure (e.g., hemoptysis, tumor resection, pneumonia). Your answers lead to the most appropriate recommendation(s). Urgent conditions are noted in the criteria with (urgent) to the right of the criteria text. Urgent conditions do not require preauthorization. A review to determine the appropriateness of the intervention is generally performed following the intervention. If there is adequate time to complete a review before performing the intervention, the urgent criteria may also be used for a prospective review. Copyright 2018 Change Healthcare LLC and/or one of its subsidiaries. All Rights Reserved. Produced in Cork, Ireland. 4
5 Review Questions Questions regarding symptoms and findings, prior imaging or diagnostic testing results, or conservative treatment are in a Yes/No, Choose one, or multiple choice (Choose all that apply) format. The rules displayed in the multiple choice questions indicate how many items must be selected to fulfill the rule. When answering questions, keep the following guidelines in mind: For questions that enable you to select more than one answer choice, you must click Next to advance to the next question. In many questions, the last answer choice is Other clinical information (add comment). If the clinical scenario does not satisfy the other answer choices, select this answer. The following recommendation displays: Current evidence does not support procedure in this clinical scenario. Selecting None of the above also displays the recommendation: Current evidence does not support procedure in this clinical scenario. Selecting More choices leads to another question with more medical conditions that may require a procedure or intervention. Selecting None of the above, more choices leads to additional questions or a recommendation. This option is used when there is a list of criteria (e.g., symptoms, findings, diagnoses, medical conditions) that must be reviewed prior to moving to the next question (e.g., risk factors for cancer, involuntary weight loss, dysphagia, odynophagia). If any of the listed criteria are present, it must be selected. If none of the listed criteria are present, select None of the above, more choices to advance to the next question or directly to a recommendation. When criteria are not available for a specific age group, the recommendation Current evidence does not support testing in this clinical scenario displays (e.g., bronchoscopy content is available for the adult patient only; strabismus repair is available for the pediatric patient only). Reviewer comments can be added at any time during the review. Step 5: Select recommendation(s) Review and select recommendation(s) to authorize the appropriate procedure(s). Based on your organizational policies, you can also select the appropriate ICD-10, CPT, and/or HCPCS codes. Recommendations The recommendations that display after you answer the questions in a particular pathway are based on the best available medical evidence and current practice. Once the medical review is completed, depending on the pathway taken, you will be led to any of the following recommendations: One procedure is recommended More than one procedure is recommended and one or more procedure can be selected, but not all the procedures need to be selected. Copyright 2018 Change Healthcare LLC and/or one of its subsidiaries. All Rights Reserved. Produced in Cork, Ireland. 5
6 More than one procedure is recommended and all procedures in a group should be selected (i.e., two or more procedures are mutually recommended). Messaging indicates which procedures must be selected together. More than one procedure is recommended but only one procedure should be selected (i.e., the procedures are mutually exclusive). Messaging indicates which procedures cannot be selected together. No procedure is recommended: Current evidence does not support testing in this clinical scenario. This occurs when all of the required criteria have not been fulfilled, the requested reason for the procedure is not included, or the content does not cover the procedure for the age group selected. No procedure is recommended: Current evidence does not support testing in this clinical scenario. This can occur when all of the required criteria have been fulfilled but the procedure is considered cosmetic based on the pathway taken. A note will display Current evidence-based literature and input from our independent panel of clinical experts does not support this procedure as medically necessary based upon the criteria selected. It may be performed, in some instances, for cosmetic reasons. Whether to perform this procedure for cosmetic purposes is a matter of local organizational policy. A procedure is recommended and flagged as This recommendation is designated as Limited Evidence in this clinical scenario. Criteria cannot be met. These procedure recommendations are also designated Secondary review required. Criteria cannot be met. A note will display Recommendations are designated as Limited Evidence based on one or more of the following: Research to date has not demonstrated this intervention s equivalence or superiority to the current standard of care. The balance of benefits and harms does not clearly favor this intervention. The clinical utility of this intervention has not been clearly established. The evidence is mixed, unclear, or of low quality. This intervention is not standard of care New technology is still being investigated. Next action(s) Your next action(s) depends on the medical review results as shown in the following table: Medical review results Select recommendation(s) Action(s) According to current evidence, one or more of the recommendations or recommendation combinations is appropriate in this clinical scenario. (View notes, if any, for details.) According to current evidence, one or more recommendations Recommended (one is selected) Recommended (two or more are selected) Mutually Exclusive (only one can be selected) Mutually Recommended (two or more must be selected) Limited Evidence Approve the recommended procedure Approve the recommended procedures Approve the recommended procedure Approve the recommended procedures Refer for secondary review or secondary medical review as Copyright 2018 Change Healthcare LLC and/or one of its subsidiaries. All Rights Reserved. Produced in Cork, Ireland. 6
7 Medical review results Select recommendation(s) Action(s) or combinations of recommendations is based on limited evidence (LE). If LE recommendations are selected, medical review is suggested based on payer policy. (View notes for details.) The criteria enable reviewers to proactively gather and document patientspecific clinical information for medical review. Mutually Exclusive Limited Evidence OR Recommended dictated by your organizational policies Limited Evidence: Refer for secondary review or secondary medical review as dictated by your organizational policies Recommended: Approve the recommended procedure(s) Current evidence does not support procedure in this clinical scenario Current evidence does not support procedure in this clinical scenario Cancel current review No recommendations were made based on the answers to the Medical Review questions. Please answer all questions. Medical review incomplete Obtain additional information from the requesting physician if needed. If the additional information satisfies the medical review, approve the recommended procedure If the additional information does not satisfy the medical review, or if no further information is available, refer for secondary review or secondary medical review as dictated by your organizational policies Procedure is considered cosmetic. Refer for secondary review or secondary medical review as dictated by your organizational policies Cancel the review Answer all questions Benchmark Length of Stay (LOS) Powered by RelayHealth Financial Benchmark length of stay (LOS) information is included in the Procedures criteria subsets that are recommended for the inpatient setting. The LOS values are derived from a select set of claims data from RelayHealth Financial and have been statistically validated. They represent geometric mean length of stay based on DRG claims data. Additionally, in the Adult content, the Centers for Medicare & Medicaid Services Medicare Severity Diagnosis Related Groups Geometric Mean Length of Stay (CMS MS-DRG GMLOS) is provided. These values create guidance designed to facilitate efficient management of a patient to a target length of stay. Copyright 2018 Change Healthcare LLC and/or one of its subsidiaries. All Rights Reserved. Produced in Cork, Ireland. 7
8 Step 6: Approve the recommended procedure(s) or refer for secondary review This step applies to InterQual Review Manager users only. If you use Review Manager, complete the primary outcome information, including the outcome date and time, next review date, priority, outcome (e.g., Approved, Referred for Secondary, Referred for Secondary Medical, or Request Canceled), and outcome comments. Outcome referral reasons Referral reasons identify reasons why the proposed request does or does not meet medical necessity or medical appropriateness. Examples include criteria issues, such as no criteria to cover indication/diagnosis/procedure, and provider issues, such as test results incomplete. Referral reasons vary from product to product and display based on the selected outcome. An organization can add specific referral reasons and create unique outcome groups to delete or hide existing referral reasons. Secondary Review Secondary review is indicated when a primary review results in any of these outcomes: Criteria subset/procedure not listed. Only the more common procedures are included in the criteria. This does not mean that the request is inappropriate, but that the request is less common, not often preauthorized, or emerging and requires secondary review. Indication not listed. The condition or symptom for performing a procedure is not listed. Only the most common conditions are listed. Criteria not available for the age group. The criteria do not cover the procedure for the age group requested. Criteria not met. When the given reason for the procedure is listed, but the required criteria are not fulfilled, the case requires secondary review and results in a recommendation of Current evidence does not support procedure in this clinical scenario. Recommendation with Limited Evidence. These procedures within a subset require secondary medical review. These criteria have been developed to provide reviewers with a basis for proactively gathering and documenting patient-specific clinical information that will facilitate secondary medical review. Recommendation with secondary review required. These procedures within a subset require secondary medical review. These criteria have been developed to provide reviewers with a basis for proactively gathering and documenting patient-specific clinical information that will facilitate secondary medical review. Patient choice and preference. The criteria delineate reasonable courses for the majority of patients. Some patients refuse certain prerequisite therapies or testing; these cases require secondary review. Copyright 2018 Change Healthcare LLC and/or one of its subsidiaries. All Rights Reserved. Produced in Cork, Ireland. 8
9 Secondary Review Process A supervisor, specialist, or physician may conduct a secondary review. The organization s policies determine the qualifications of the reviewers, as well as the extent to which secondary review is conducted to render a review outcome. The secondary reviewer determines the medical necessity of the request based on a review of the medical record, discussions with the provider or referring physician, and by applying clinical experience. When conducting a secondary review: If the secondary reviewer agrees with the requested procedure, approve the request and select the approved procedure. If the secondary reviewer does not agree with the request, the optimal alternate treatment for this patient may be discussed with the requesting provider. If the requesting provider does not agree with the secondary reviewer s determination, a specialist may become involved in the review process. Copyright 2018 Change Healthcare LLC and/or one of its subsidiaries. All Rights Reserved. Produced in Cork, Ireland. 9
Review Process. Introduction. Reference materials. InterQual SIM plus Criteria
InterQual SIM plus Criteria Review Process Introduction As part of the InterQual Care Planning family of products, InterQual SIM plus provide healthcare organizations with evidence-based retrospective
More informationMedicare: This subset aligns with the requirements defined by CMS and is for the review of Medicare and Medicare Advantage beneficiaries
InterQual Level of Care Criteria Subacute & SNF Criteria Review Process Introduction InterQual Level of Care Criteria support determining the appropriateness of admission, continued stay, and discharge
More informationReference materials are provided with the criteria and should be used to assist in the correct interpretation of the criteria.
InterQual Level of Care Criteria Rehabilitation Criteria Review Process Introduction InterQual Level of Care Criteria support determining the appropriateness of admission, continued stay, and discharge
More informationReview Process. Introduction. InterQual Level of Care Criteria Long-Term Acute Care Criteria
InterQual Level of Care Criteria Long-Term Acute Care Criteria Review Process Introduction InterQual Level of Care Criteria support determining the appropriateness of Long-Term Acute Care (LTAC) admission,
More informationReview Process. Introduction. InterQual Behavioral Health Criteria Substance Use Disorders. Reference Materials
InterQual Behavioral Health Criteria Substance Use Disorders Review Process Introduction InterQual Behavioral Health Substance Use Disorders Criteria provide support for determining the clinical appropriateness
More informationINTERQUAL DURABLE MEDICAL EQUIPMENT CRITERIA REVIEW PROCESS
RP-1 RP-2 ORGANIZATION InterQual Durable Medical Equipment (DME) criteria are organized according to General and Senior categories. General criteria are clinically appropriate criteria for adult and/or
More informationReview Process. Introduction. InterQual Level of Care Criteria Subacute & SNF Criteria. Reference materials. Informational notes
InterQual Level of Care Criteria Subacute & SNF Criteria Review Process Introduction InterQual Level of Care Criteria support determining the appropriateness of admission, continued stay, and discharge
More informationINTERQUAL REHABILITATION CRITERIA REVIEW PROCESS
REVIEW RP-1 RP-2 INTERQUAL CRITERIA REVIEW REVIEW The InterQual Criteria provide support for determining the appropriateness of admission, continued stay and discharge destination. The Acute Rehabilitation
More informationInterQual Review Manager Guide to Conducting Reviews. McK. Change Healthcare LLC Product Support
InterQual Review Manager 17.0 Guide to Conducting Reviews McK Change Healthcare LLC www.changehealthcare.com Product Support 800.274.8374 General Terms: Change Healthcare LLC and/or one of its subsidiaries
More informationPayment Policy: Assistant Surgeon Reference Number: CC.PP.029 Product Types: ALL
Payment Policy: Reference Number: CC.PP.029 Product Types: ALL Effective Date: 01/01/2014 Last Review Date: 03/01/2018 Coding Implications Revision Log See Important Reminder at the end of this policy
More informationOutpatient Hospital Facilities
Outpatient Hospital Facilities Chapter 6 Chapter Outline Introduce students to 1. Different outpatient facilities 2. Different departments involved in the reimbursement process 3. The Chargemaster 4. Terminology
More informationMagellan Complete Care of Virginia Musculoskeletal Care Management (MSK)Program
Magellan Healthcare 1 Magellan Complete Care of Virginia Musculoskeletal Care Management (MSK)Program 1 National Imaging Associates, Inc. is a subsidiary of Magellan Healthcare, Inc. Magellan Healthcare
More informationProgram Selection Criteria: Bariatric Surgery
Program Selection Criteria: Bariatric Surgery Released June 2017 Blue Cross Blue Shield Association is an association of independent Blue Cross and Blue Shield companies. 2013 Benefit Design Capabilities
More informationPayment Policy: High Complexity Medical Decision-Making Reference Number: CC.PP.051 Product Types: ALL
Payment Policy: High Complexity Medical Decision-Making Reference Number: CC.PP.051 Product Types: ALL Effective Date: 6/2017 Last Review Date: See Important Reminder at the end of this policy for important
More informationHMSA s Interventional Pain Management and Spine Surgery Program
HMSA s Interventional Pain Management and Spine Surgery Program Presented by: Laurie Kim, Director, Provider Relations and Account Management Hawai i Magellan Healthcare 1 Training Program 1 National Imaging
More informationClinical Development Process 2017
InterQual Clinical Development Process 2017 InterQual Overview Thousands of people in hospitals, health plans, and government agencies use InterQual evidence-based clinical decision support content to
More information2017 SPECIALTY REPORT ANNUAL REPORT
2017 SPECIALTY REPORT ANNUAL REPORT National Commission on Certification of Physician Assistants Table of Contents Message from the President... 3 About the Data Collection and Methodology...4 All Specialties....
More information2018 Biliary Reimbursement Coding Fact Sheet
The information contained in this document is provided for informational purposes only and represents no statement, promise, or guarantee by Cordis Corporation concerning levels of reimbursement, payment,
More informationPREVENTIVE MEDICINE AND SCREENING POLICY
UnitedHealthcare Oxford Reimbursement Policy PREVENTIVE MEDICINE AND SCREENING POLICY Policy Number: ADMINISTRATIVE 238.19 T0 Effective Date: July 1, 2018 Table of Contents Page INSTRUCTIONS FOR USE...
More informationObservation Services Tool for Applying MCG Care Guidelines
In the event of a conflict between a Clinical Payment and Coding Policy and any plan document under which a member is entitled to Covered Services, the plan document will govern. Plan documents include
More informationOBSERVATION CARE EVALUATION AND MANAGEMENT CODES POLICY
OBSERVATION CARE EVALUATION AND MANAGEMENT CODES POLICY UnitedHealthcare Oxford Reimbursement Policy Policy Number: ADMINISTRATIVE 232.10 T0 Effective Date: March 1, 2017 Table of Contents Page INSTRUCTIONS
More informationVIRGINIA WORKERS COMPENSATION MEDICAL FEE SCHEDULES GROUND RULES JUNE 5, 2017
VIRGINIA WORKERS COMPENSATION MEDICAL FEE SCHEDULES GROUND RULES JUNE 5, 2017 Contents Introduction... 3 Definitions... 4 General Information... 11 Application of the Medical Fee Schedules... 11 Exclusions
More informationThe presenter has owns Kelly Willenberg, LLC in relation to this educational activity.
Kelly M Willenberg, MBA, BSN, CCRP, CHC, CHRC 1 The presenter has owns Kelly Willenberg, LLC in relation to this educational activity. 2 1 Medical Necessity when you submit claims Coding for qualifying
More informationHealth Alliance. Utilization Management Changes Overview. Maxine Wallner Director Provider Services. February 2017
Health Alliance Utilization Management Changes Overview February 2017 Maxine Wallner Director Provider Services Agenda Decision Overview Utilization Management Program Changes Expansions and modifications
More informationA. All inpatient facility services - Medical, Substance Abuse, and Behavioral Health admissions require authorization.
Medicare Authorization Grid FIDELIS CARE AUTHORIZATION REQUIREMENTS Benefit/Service Detail SERVICES AND PROCEDURES WHICH REQUIRE AUTHORIZATION REVISED 2/1/16 I. Inpatient Admissions-All inpatient admissions
More informationWait Time Information in Priority Areas: Definitions
Wait Time Information in Priority Areas: Definitions 1 Background In 2004, Canada's first ministers agreed to work towards reducing wait times for five priority areas: cancer treatment, cardiac care, diagnostic
More information2015 Physician Licensure Survey
2015 Physician Licensure Survey 1. What is your racial background? Please select all that apply. White American Indian or Alaska Native Native Hawaiian/Pacific Islander Black or African American Asian
More informationUsing Clinical Criteria for Evaluating Short Stays and Beyond
Using Clinical Criteria for Evaluating Short Stays and Beyond Georgeann Edford I. History A. Social Security Act Medical Necessity and Utilization Review 1. Items or services necessary for the diagnosis
More informationModifier -25 Significant, Separately Identifiable E/M Service
Manual: Policy Title: Reimbursement Policy Modifier -25 Significant, Separately Identifiable E/M Service Section: Modifiers Subsection: None Date of Origin: 1/1/2000 Policy Number: RPM028 Last Updated:
More informationINTERQUAL ACUTE CRITERIA REVIEW PROCESS
REVIEW RP-1 RP-2 REVIEW The InterQual Acute Criteria provide support for determining the appropriateness of admission, continued stay and discharge. The Acute Criteria address the observation, critical,
More informationCigna Medical Coverage Policy
Cigna Medical Coverage Policy Subject Observation Care Table of Contents Coverage Policy... 1 General Background... 2 Coding/Billing Information... 4 References... 5 Effective Date... 10/15/2014 Next Review
More informationA. All inpatient facility services - Medical, Substance Abuse, and Behavioral Health admissions require authorization.
Medicare Authorization Grid FIDELIS CARE AUTHORIZATION REQUIREMENTS Benefit/Service Detail SERVICES AND PROCEDURES WHICH REQUIRE AUTHORIZATION EFFECTIVE 1/1/2017 I. Inpatient Admissions: All inpatient
More informationBenefit Explanation And Limitations
Benefit Explanation And Limitations SFHP providers supply many medical benefits and services, some of which are itemized on the following pages. For specific information not covered in this table, please
More informationBlue Choice PPO SM Provider Manual - Preauthorization
In this Section Blue Choice PPO SM Provider Manual - The following topics are covered in this section. Topic Page Overview E 3 What Requires E 3 evicore Program E 3 Responsibility for E 3 When to Preauthorize
More informationINTERQUAL BEHAVIORAL HEALTH CRITERIA RESIDENTIAL & COMMUNITY-BASED TREATMENT ADULT PSYCHIATRY ADULT SUBSTANCE USE REVIEW PROCESSES
INTERQUAL BEHAVIORAL HEALTH CRITERIA RESIDENTIAL & COMMUNITY-BASED TREATMENT ADULT PSYCHIATRY ADULT SUBSTANCE USE ES RP-1 RP-2 ORGANIZATION & AGE PARAMETERS Behavioral Health Level of Care for Adult Residential
More informationSample page. Orthopaedics: Hips & Below. A comprehensive illustrated guide to coding and reimbursement CODING COMPANION
CODING COMPANION 2018 Orthopaedics: Hips & Below A comprehensive illustrated guide to coding and reimbursement POWER UP YOUR CODING with Optum360, your trusted coding partner for 32 years. Visit optum360coding.com.
More informationNEW PATIENT VISIT POLICY
NEW PATIENT VISIT POLICY UnitedHealthcare Oxford Reimbursement Policy Policy Number: ADMINISTRATIVE 229.12 T0 Effective Date: November 1, 2017 Table of Contents Page INSTRUCTIONS FOR USE... 1 APPLICABLE
More informationPOLICY AND REGULATIONS MANUAL TITLE: HOSPITALIZATION & MEDICAL NECESSITY REVIEW
Page Number: 1 of 21 TITLE: HOSPITALIZATION & MEDICAL NECESSITY REVIEW PURPOSE: To provide guidelines for the hospitalization of patients and for assignment of the appropriate Status to patients in the
More informationFrequently Asked Questions (FAQ) The Harvard Pilgrim Independence Plan SM
Frequently Asked Questions (FAQ) The Harvard Pilgrim Independence Plan SM Plan Year: July 2010 June 2011 Background The Harvard Pilgrim Independence Plan was developed in 2006 for the Commonwealth of Massachusetts
More informationCompliant Documentation for Coding and Billing. Caren Swartz CPC,CPMA,CPC-H,CPC-I
Compliant Documentation for Coding and Billing Caren Swartz CPC,CPMA,CPC-H,CPC-I caren@practiceintegrity.com Disclaimer Information contained in this text is based on CPT, ICD-9-CM and HCPCS rules and
More informationCoding and Payment Guide for Chiropractic Services. A comprehensive coding, billing, and reimbursement resource for chiropractic services
Coding and Payment Guide for Chiropractic Services A comprehensive coding, billing, and reimbursement resource for chiropractic services 2014 Contents Introduction...1 Coding Systems... 1 Claim Forms...
More informationReimbursement Information for Contrast Enhanced Spectral Mammography (CESM) Services 1
GE Healthcare Reimbursement Information for Contrast Enhanced Spectral Mammography (CESM) Services 1 May 2018 www.gehealthcare.com/reimbursement This advisory addresses Medicare coding, coverage and payment
More informationPacificSource Community Solutions Referral Frequently Asked Questions
PacificSource Community Solutions Referral Frequently Asked Questions **For Provider Use Only** 1. What is the difference between a referral and a preapproval? A referral is the process by which the member
More informationPresented by: Jodie Edmonds VP Medicaid Revenue Consultant Passport Health Communications
Presented by: Jodie Edmonds VP Medicaid Revenue Consultant Passport Health Communications Complete and correct coding of claims will become more important, and will have an effect on claim payment. The
More informationBlue Distinction Centers for Bariatric Surgery 2017 Provider Survey
Blue Distinction Centers for Bariatric Surgery 2017 Provider Survey Printed version of this document is for reference purposes only. A completed Provider Survey will need to be submitted via the BD Link
More informationDepartment of Defense INSTRUCTION
Department of Defense INSTRUCTION NUMBER 6025.8 September 23, 1996 ASD(HA) SUBJECT: Ambulatory Procedure Visit (APV) References: (a) DoD Instruction 6025.8, "Same Day Surgery," July 21, 1986 (hereby canceled)
More informationAND PROCEDURES WHICH REQUIRE AUTHORIZATION EFFECTIVE
Medicare Authorization Grid FIDELIS CARE AUTHORIZATION REQUIREMENTS Benefit/Service Detail SERVICES AND PROCEDURES WHICH REQUIRE AUTHORIZATION EFFECTIVE 1/1/2018 I. Inpatient Admissions: All inpatient
More informationINTERQUAL BEHAVIORAL HEALTH CRITERIA RESIDENTIAL & COMMUNITY-BASED TREATMENT ADOLESCENT & CHILD PSYCHIATRY ADOLESCENT SUBSTANCE USE REVIEW PROCESSES
INTERQUAL BEHAVIORAL HEALTH CRITERIA RESIDENTIAL & COMMUNITY-BASED TREATMENT ADOLESCENT & CHILD PSYCHIATRY ADOLESCENT SUBSTANCE USE REVIEW PROCESSES RP-15 RP-16 ORGANIZATION & AGE PARAMETERS Behavioral
More information2018 MIPS Quality Performance Category Measure Information for the 30-Day All-Cause Hospital Readmission Measure
2018 MIPS Quality Performance Category Measure Information for the 30-Day All-Cause Hospital Readmission Measure A. Measure Name 30-day All-Cause Hospital Readmission Measure B. Measure Description The
More informationBasic Teaching Physician Presence and Documentation
Basic Teaching Physician Presence and Documentation Welcome to the Children s University Medical Group (CUMG) training on the Teaching Physician Presence and Documentation. The goal of this module is to
More informationNotification/Prior Authorization for Certain Surgical Procedures Frequently Asked Questions
Notification/Prior Authorization for Certain Surgical Procedures Frequently Asked Questions Key Points For many UnitedHealthcare commercial plan and UnitedHealthcare Community Plan members, we require
More informationAdministration ~ Education and Training (919)
The Accreditation Council for Graduate Medical Education requires the educational program to provide a curriculum that must contain the following educational components to its Trainees; overall educational
More informationReporting Diagnosis Codes in ICD-10
Reporting Diagnosis Codes in ICD-10 My physician treated a patient for dysphasia secondary to an acute cerebral infarction in the inpatient rehab hospital. Do I need to report two diagnosis codes in ICD-10?
More informationMEDICAL POLICY No R2 TELEMEDICINE
Summary of Changes Clarifications: Page 1, Section I. A 6, additional language added for clarification. Deletions: Additions Page 4, Section IV, Description, additional language added in regards to telemedicine.
More informationBenefit Explanation And Limitations
Benefit Explanation And Limitations SFHP providers supply many medical benefits and services, some of which are itemized on the following pages. For specific information not covered in this table, please
More informationCorporate Reimbursement Policy Telehealth
Corporate Reimbursement Policy Telehealth File Name: Origination: Last Review Next Review: telehealth 11/1997 12/2017 12/2018 Description Telehealth is a potentially useful tool that, if employed appropriately,
More informationLIFE SCIENCES CONTENT
Model Coding Curriculum Checklist Approved Coding Certificate Programs must be based on content appropriate to prepare students to perform the role and functions associated with clinical coders in healthcare
More informationPayment Policy: Visits On Same Day As Surgery Reference Number: CC.PP.040 Product Types: ALL Effective Date: 03/01/2018
Payment Policy: Visits On Same Day As Surgery Reference Number: CC.PP.040 Product Types: ALL Effective Date: 03/01/2018 Revision Log See Important Reminder at the end of this policy for important regulatory
More informationSubject: Member Pre-Authorization Page 1 of 5
Subject: Member Pre-Authorization Page 1 of 5 Objective: I. To ensure appropriate utilization of Tuality Health Alliance (THA) resources, including the resource networks available through Providence Health
More informationOVERALL GOALS AND OBJECTIVES FOR EACH RESIDENT LEVEL 3 rd YEAR GENERAL SURGERY RESIDENT PATIENT CARE
OVERALL GOALS AND OBJECTIVES FOR EACH RESIDENT LEVEL CRITERIA FOR ADVANCEMENT TO PGY-4 YEAR: Satisfactory completion of all rotations and fulfillment of all performance objectives listed above as judges
More informationProcedural andpr Diagnostic Coding. Copyright 2012 Delmar, Cengage Learning. All rights reserved.
Procedural andpr Diagnostic Coding What is Coding? Converting descriptions of disease, injury, procedures, and services into numeric or alphanumeric descriptors Accurate coding maximizes reimbursement
More informationProvider Preventable Conditions: Health Care Acquired Conditions and Present on Admission Policy
Provider Preventable Conditions: Health Care Acquired Conditions and Present on Admission Policy Policy Number 2018F7002A Annual Approval Date 3/14/2018 Approved By Reimbursement Policy Oversight Committee
More informationCONSULTATION SERVICES POLICY
CONSULTATION SERVICES POLICY UnitedHealthcare Oxford Reimbursement Policy Policy Number: ADMINISTRATIVE 256.3 T0 Effective Date: October 1, 2017 Table of Contents Page INSTRUCTIONS FOR USE... 1 APPLICABLE
More informationMEDICAL POLICY No R1 TELEMEDICINE
Summary of Changes MEDICAL POLICY TELEMEDICINE Effective Date: March 1, 2016 Review Dates: 12/12, 12/13, 11/14, 11/15 Date Of Origin: December 12, 2012 Status: Current Clarifications: Deletions: Pg. 4,
More informationProvider Frequently Asked Questions (FAQs)
1 Provider Frequently Asked Questions (FAQs) November 2012 BlueAdvantage Administrators of Arkansas will be working with AIM Specialty HealthSM (AIM) on a new Integrated Imaging Program for outpatient
More informationColorado Board of Pharmacy Rules pertaining to Collaborative Practice Agreements
6.00.00 PHARMACEUTICAL CARE, DRUG THERAPY MANAGEMENT AND PRACTICE BY PROTOCOL. 6.00.10 Definitions. a. "Pharmaceutical care" means the provision of drug therapy and other pharmaceutical patient care services
More informationMedicaid Benefits at a Glance
Medicaid Benefits at a Glance Mountain Health Trust Benefits Children (0 up to 21 years) Ambulatory Surgical Center Services Any distinct entity that operates exclusively for the purpose of providing surgical
More informationLong Term Care Hospital Clinical Coverage Policy No: 2A-2 Services (LTCH) Amended Date: October 1, Table of Contents
Long Term Care Hospital Clinical Coverage Policy No: 2A-2 Services (LTCH) Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 1.1 Definitions... 1 2.0 Eligibility Requirements...
More informationSurgical Care, Centered on You
General Surgery Surgical Care, Centered on You Having surgery is an important decision, and so is choosing where to have surgery. At Woman s, your surgery will be performed by experienced specialists and
More informationPGY-1 Overall Goals & Objectives
PGY-1 Overall Goals & Objectives PGY-1 residents are expected to accomplish and maintain the following objectives: Develop personal values and interpersonal skills appropriate for the surgical resident
More informationComplete Home Health Icd-9-cm Diagnosis Coding Manual 2012
Complete Home Health Icd-9-cm Diagnosis Coding Manual 2012 Download PDF ICD 9 CM 2015 for Physicians Volumes 1 and 2 Professional Complete Home. Time to Update your ICD-10-CM Implementation Plan by Teresa
More informationMolina Healthcare of Illinois Prior Authorization Codification List Q ILUM182.1
Q3-2018 ILUM182.1 MOLINA HEALTHCARE OF ILLINOIS 2018 PRIOR AUTHORIZATION CODIFICATION LIST The Molina Healthcare of Illinois (Molina) is reviewed for updates quarterly, or as deemed necessary to meet the
More informationPROFESSIONAL MEDICAL CODING AND BILLING WITH APPLIED PCS LEARNING OBJECTIVES
The Professional Medical Coding and Billing with Applied PCS classes have been designed by experts with decades of experience working in and teaching medical coding. This experience has led us to a 3-
More informationINTERQUAL LONG-TERM ACUTE CARE CRITERIA REVIEW PROCESS
REVIEW RP-1 RP-2 INTERQUAL CRITERIA REVIEW REVIEW The InterQual Criteria provide support for determining the appropriateness of admission, continued stay and appropriate discharge destinations. Supporting
More informationDisclosure of Proprietary Interest
HomeTown Health HCCS Hospital Consortium Project: Track 3- Clinical Documentation: Strategies for Sharpening Focus Jenan Custer RHIT, CCS, CPC, CDIP AHIMA Approved ICD-10-CM/PCS Trainer Director of Coding
More informationThis policy describes the appropriate use of new patient evaluation and management (E/M) codes.
Private Property of Florida Blue. This payment policy is Copyright 2017, Florida Blue. All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission
More informationSample page. Podiatry. A comprehensive illustrated guide to coding and reimbursement CODING COMPANION
CODING COMPANION 2018 Podiatry A comprehensive illustrated guide to coding and reimbursement POWER UP YOUR CODING with Optum360, your trusted coding partner for 32 years. Visit optum360coding.com. Contents
More informationDescriptions: Provider Type and Specialty
Descriptions: Provider Type and Specialty PROVIDER TYPE/SPECIALTY ADULT PRIMARY CARE Provides care for adults by treating common health problems, performing check-ups and providing prevention services.
More informationSame Day/Same Service Policy, Professional
Same Day/Same Service Policy, Professional Policy Number 2018R0002D Annual Approval Date 7/11/2018 Approved By REIMBURSEMENT POLICY CMS-1500 Reimbursement Policy Oversight Committee IMPORTANT NOTE ABOUT
More informationFacility-Based Behavioral Health Program Professional Fees Reimbursement Policy Annual Approval Date. Approved By
Policy Number 2016RP505A Facility-Based Behavioral Health Program Professional Fees Reimbursement Policy Annual Approval Date 09/30/2016 Approved By Optum Behavioral Reimbursement Committee IMPORTANT NOTE
More informationPOWER MOBILITY DEVICE REGULATION AND PAYMENT
POWER MOBILITY DEVICE REGULATION AND PAYMENT Today s Actions: The Centers for Medicare & Medicaid Services (CMS) is issuing a final rule implementing provisions in the Medicare Modernization Act (MMA)
More informationModifier 53 Discontinued Procedure
Manual: Policy Title: Reimbursement Policy Modifier 53 Discontinued Procedure Section: Modifiers Subsection: none Date of Origin: 9/13/2007 Policy Number: RPM018 Last Updated: 5/8/2017 Last Reviewed: 5/12/2017
More informationJaci Johnson, CPC,CPMA,CEMC,CPC H,CPC I President, Practice Integrity, LLC Disclaimer
Advanced Evaluation and Management More than a roll of the dice? History Exam Medical Decision Making Jaci Johnson, CPC,CPMA,CEMC,CPC H,CPC I President, Practice Integrity, LLC jaci@practieintegrity.com
More informationMagellan Healthcare 1 Medical Specialty Solutions
Magellan Healthcare 1 Medical Specialty Solutions Horizon NJ Health 1 National Imaging Associates, Inc. is a subsidiary of Magellan Healthcare, Inc. Magellan Healthcare Training 2 Magellan Healthcare Agenda
More informationREPORT 5 OF THE COUNCIL ON MEDICAL SERVICE (I-09) Radiology Benefits Managers (Reference Committee J) EXECUTIVE SUMMARY
REPORT OF THE COUNCIL ON MEDICAL SERVICE (I-0) Radiology Benefits Managers (Reference Committee J) EXECUTIVE SUMMARY At the 00 Annual Meeting, the House of Delegates adopted as amended Resolution, which
More informationSurgical Variance Report General Surgery
Surgical Variance Report General Surgery Table of Contents Introduction to Surgical Variance Report: General Surgery 1 Foreword 2 Data used in this report 3 Indicators measured in this report 4 Laparoscopic
More informationObservation Services Tool for Applying MCG Care Guidelines Policy
In the event of conflict between a Clinical Payment and Coding Policy and any plan document under which a member is entitled to Covered Services, the plan document will govern. Plan documents include,
More informationObservation Care Evaluation and Management Codes Policy
Policy Number Observation Care Evaluation and Management Codes Policy 2017R0115A Annual Approval Date 3/8/2017 Approved By Reimbursement Policy Oversight Committee IMPORTANT NOTE ABOUT THIS You are responsible
More information2013 Physician Inpatient/ Outpatient Revenue Survey
Physician Inpatient/ Outpatient Revenue Survey A survey showing net annual inpatient and outpatient revenue generated by physicians in various specialties on behalf of their affiliated hospitals Merritt
More informationDo I Have the Right Credential?
Do I Have the Right Credential? AAPC National Conference April 2013 Judy Wilson CPC,CPC-H,CPCO,CPC-P,CPPM,CPCI,CANPC,CMRS Jaci Johnson CPC,CPC-H,CPMA,CEMC,CPC-I Disclaimer Information contained in this
More informationIn the middle of the night, a patient arrives with a leaking abdominal aortic
Clinical management Specialty staff versus generalists: How do ORs strike the balance? In the middle of the night, a patient arrives with a leaking abdominal aortic aneurysm, and the surgeon wants to insert
More informationIMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY
Global Surgery Policy Number GLS03272013RP Approved By UnitedHealthcare Medicare Committee Current Approval Date 04/09/2014 IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY This policy is applicable to UnitedHealthcare
More informationTelemedicine services $0 copay Not applicable Primary care provider (PCP) CYD/Coinsurance CYD/Coinsurance CYD/Coinsurance CYD/Coinsurance
Calendar Year Deductible (CYD) 2 Plan includes an embedded individual deductible provision. An embedded deductible combines individual and family deductibles in $4,000 Single / $8,000 Family $12,000 Single
More informationBlue Care Network Physical & Occupational Therapy Utilization Management Guide
Blue Care Network Physical & Occupational Therapy Utilization Management Guide (Also applies to physical medicine services by chiropractors) January 2016 Table of Contents Program Overview... 1 Physical
More informationUW HEALTH JOB DESCRIPTION
NURSE CASE MANAGER - ED Job Code: 801009 FLSA Status: Mgt. Approval: B Liegel Date: 6-18 Department: Coordinated Care Department 93070 HR Approval: M Buenger Date: 6-18 JOB SUMMARY The Nurse Case Manager,
More informationAdvanced Evaluation and. AAPC Regional Conference Chicago 10/27/12
Advanced Evaluation and Management AAPC Regional Conference Chicago 10/27/12 Jaci Johnson, CPC,CPMA,CEMC,CPC H,CPC I President, Practice Integrity, LLC jaci@practiceintegrity.com Disclaimer Information
More informationThis document is updated quarterly. Please check this document prior to PA submission as codes may be removed or added. All codes listed require PA.
, PA Code Matrix IMPORTANT NOTICES September 1, 2016 This document is updated quarterly. Please check this document prior to PA submission as codes may be removed or added. All codes listed require PA.
More informationHow Allina Saved $13 Million By Optimizing Length of Stay
Success Story How Allina Saved $13 Million By Optimizing Length of Stay EXECUTIVE SUMMARY Like most large healthcare systems throughout the country, Allina Health s financial health improves dramatically
More informationChapter 13 Section 2. Billing And Coding Of Services Under Ambulatory Payment Classifications (APC) Groups
Outpatient Prospective Payment System (OPPS)-Ambulatory Payment Classification (APC) Chapter 13 Section 2 Billing And Coding Of Services Under Ambulatory Payment Classifications (APC) Groups Issue Date:
More informationOptima Health Provider Manual
Optima Health Provider Manual Supplemental Information For Ohio Facilities and Ancillaries This supplement of the Optima Health Ohio Provider Manual provides information of specific interest to Participating
More information