Institutional Medical Necessity Inclusion Maintenance

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To begin configuring institutional medical necessity inclusions, from the ClaimStaker toolbar, select Configuration, then Medical Necessity Inclusion Maintenance, then Institutional.

The Institutional Medical Necessity Inclusion Maintenance page displays with a list of any inclusions you have already created. To make locating an inclusion easier, they can be sorted by CPT from and through, modifier, code from and through, revenue or ICD-10 code type, or by edit message by selecting the link on the appropriate column header.

REMINDER: Working payers must have been previously added via the Payer Maintenance page in order to be available on the Institutional Medical Necessity Inclusion Maintenance page. Otherwise, the "All Payers, Commercial or Otherwise" option will be the only option available in the working payer drop-down menu.

To view inclusions created for all payers, select All Payers, Commercial or Otherwise from the Working Payer drop-down menu. To view medical necessity inclusions for a specific payer, select the desired payer from the Working Payer drop-down menu. Select the Get Inclusions button. If no medical necessity inclusions have been created for a working payer, there will be a message stating, "No inclusions have been created for this working payer."

Screenshot of the Working Payer drop-down list on the Institutional Medical Necessity Inclusion Maintenance page. All Payers, Commercial or Otherwise has been selected and the Get Inclusions button is being selected

Adding institutional medical necessity inclusions

To add a new institutional medical necessity inclusion, select the Add button on the Institutional Medical Necessity Inclusion Maintenance page. This opens the Add Institutional Medical Necessity Inclusion page.

In order for the inclusion addition to be successful, please remember the following tips when entering a medical necessity inclusion:

To add an inclusion:

  1. Enter the appropriate code range in the CPT From and CPT Through fields.

  2. Select either the Revenue or ICD-10 radio button in the Code Type section.

  3. Enter the appropriate code range in the Revenue Code From and Revenue Code Through fields or the ICD-10 Code From and ICD-10 Code Through fields, based on the code type selected.

  4. Specify modifiers (if applicable).

  5. Enter the edit message you wish to appear for this inclusion in the Edit Message field.

  6. Select Apply to save your new inclusion and return to the Institutional Medical Necessity Inclusion Maintenance page.

    Screenshot of the Inclusion Information section. There are eight fields for adding inclusion information. The CPT From and CPT Through fields have 20102 entered. The ICD-10 Code Type radio button is selected. The ICD From and ICD Through fields have M99.52 entered. The Ignore Modifier check box has been selected. The modifiers fields are blank. The Comment field has the following entry: This code combination does not show medical necessity.

Your new medical necessity inclusion now appears in your list of inclusions.

Modifying institutional medical necessity inclusions

Changes to institutional medical necessity inclusions are made from the Institutional Medical Necessity Inclusion Maintenance page. To make locating an inclusion easier, they may be sorted by CPT code, modifier, ICD code, ICD type, or by edit message by selecting the link on the appropriate column header. Once you locate the inclusion to modify, select the icon under the Edit column for that inclusion.

Screenshot of the Institutional Medical Necessity Inclusions table with thirteen columns and two rows. The icon under the Edit column for CPT 20102 is being selected.

Selecting the Edit icon takes you to the Modify Institutional Medical Necessity Inclusion page where you can make changes to the inclusion. Simply enter the necessary modifications and select the Apply button to save your changes and return to the Institutional Medical Inclusion Maintenance page.

Screenshot of the Inclusion Information section. CPT code 20103 is being entered in the CPT Through field.

You are presented with a message stating the update was successful.

Deleting medical necessity inclusions

To delete a medical necessity inclusion, simply select the icon for the inclusion under the Delete column on the Institutional Medical Necessity Inclusion Maintenance page.

Screenshot of the Institutional Medical Necessity Inclusions table. The icon under the Delete column for CPT 20102 is being selected.

You are presented with a message that the deletion was successful and the inclusion is removed from the list.

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