Professional Medical Necessity Inclusion Maintenance

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To begin configuring your professional medical necessity inclusions, from the ClaimStaker toolbar, select Configuration, then Medical Necessity Inclusion Maintenance, then Professional.

The Professional 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 code, modifier, ICD code, ICD 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 Professional 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 Professional Medical Necessity Inclusion Maintenance page. All Payers, Commercial or Otherwise has been selected and the Get Inclusions button is being selected

Adding professional medical necessity inclusions

To add a new professional medical necessity inclusion, select the Add button on the Professional Medical Necessity Inclusion Maintenance page. This opens the Add Professional 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 CPT and ICD code ranges in the CPT From, CPT Through, ICD Code From, and ICD Code Through fields.

  2. Specify modifiers (if applicable).

  3. Specify whether the inclusion will apply to ICD-9 or ICD-10 codes (ICD-10 is selected by default).

  4. Enter the edit message you wish to appear for the inclusion.

  5. Select Apply to save your new inclusion and return to the Professional 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 CPT code 20102 entered. The ICD Code From and ICD Code Through fields have M99.52 entered. The Ignore Modifier check box has been selected. The Modifiers field is blank. The ICD-10 radio button is selected. 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 medical necessity inclusions

Changes to medical necessity inclusions are made from the Professional 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 Professional Medical Necessity Inclusions table with thirteen columns and two rows. The icon under the Edit column for CPT code 20102 is being selected.

Selecting the Edit icon takes you to the Modify Professional 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 Professional Medical Inclusion Maintenance page.

Screenshot of the Inclusion Information section of the Modify Professional Medical Necessity Inclusion page. 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 Professional Medical Necessity Inclusion Maintenance page.

Screenshot of the Professional Medical Necessity Inclusions table. The icon under the Delete column for CPT code G0180 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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