Professional Medical Necessity Exclusion Maintenance

To begin configuring professional medical necessity exclusions, select Configuration then Medical Necessity Exclusion Maintenance then Professional. The Professional Medical Necessity Exclusion Maintenance page appears.

Here, you can add an exclusion and view a list of exclusions created for all payers or for specific working payers. To make locating an exclusion easier, they can be sorted by CPT code, modifier, ICD code, or by exclusion comment 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 Exclusion Maintenance page.

To view exclusions created for all payers, select All Payers, Commercial or Otherwise from the drop-down menu. To view medical necessity exclusions for a specific working payer:

1. Select the desired payer from the Working Payer drop-down menu.


2. Select the Get Exclusions button. (If no medical necessity exclusions have been created for the working payer, there will be a message stating, "No professional medical necessity exclusions have been created for this working payer.")

   

Adding professional medical necessity exclusions

To add a new professional medical necessity exclusion, select the Add button on the Professional Medical Necessity Exclusion Maintenance page. This opens the Add Professional Medical Necessity Exclusion page.

TIP: Review current entries for the payer before adding a new exclusion to ensure you are not duplicating an existing entry.

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

• To enter a single CPT or ICD code, enter the specific code in both the From and Through fields for the appropriate code type (see example below).


• If entering a range of CPT or ICD codes, the lower number must be in the appropriate From field and the higher number in the Through field.


• The Ignore Modifiers check box must be checked if there is no modifier for the exclusion.

To create an exclusion:

1. Enter the appropriate CPT and ICD code ranges in the CPT From and CPT Through, Primary ICD From, and Primary ICD Through fields.


2. Specify modifiers (if applicable).


3. Indicate whether to use ICD-9 or ICD-10 coding by selecting the ICD-9 or ICD-10 radio button (ICD-10 is selected by default).


4. Enter an exclusion comment for this exclusion in the Comment field if desired.


5. Select the Apply button to save your new exclusion and return to the Professional Medical Necessity Exclusion Maintenance page.

   

Your new professional medical necessity exclusion now appears in your list of exclusions.

Modifying professional medical necessity exclusions

Changes to professional medical necessity exclusions are made from the Professional Medical Necessity Exclusion Maintenance page. It includes the following columns: CPT From, CPT Through, Ignore Modifiers, Modifier 1, 2, 3, and 4, Primary ICD From and Primary ICD Through, ICD Type, Comment, Edit, and Delete. To make locating an exclusion easier, they may be sorted by CPT code, modifier, ICD code, or by comment by selecting the link on the appropriate column header. Once you locate the exclusion to modify, select the icon under the Edit column for that exclusion.

Selecting the Edit icon takes you to the Modify Professional Medical Necessity Exclusion page where you can make changes to the exclusion. Simply enter the necessary modifications (such as adding an edit comment as shown below) and select the Apply button to save your changes and return to the Professional Medical Exclusion Maintenance page.

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

Deleting professional medical necessity exclusions

To delete a professional medical necessity exclusion, simply select the icon for the exclusion under the Delete column on the Professional Medical Necessity Exclusion Maintenance page.

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

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