DOCSLIB.ORG

Methods Series Report #2016-02

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Methods Series Report #2016-02 HCUP Methods Series Contact Information: Healthcare Cost and Utilization Project (HCUP) Agency for Healthcare Research and Quality 5600 Fishers Lane Room 07W17B Mail Stop 7W25B Rockville, MD 20857 http://www.hcup-us.ahrq.gov For Technical Assistance with HCUP Products: Email: [email protected] or Phone: 1-866-290-HCUP Recommended Citation: Gibson T, Casto A, Young J, Karnell L, Coenen N. Impact of ICD-10- CM/PCS on Research Using Administrative Databases. HCUP Methods Series Report # 2016- 02 ONLINE. July 25, 2016. U.S. Agency for Healthcare Research and Quality. Available: http://www.hcup-us.ahrq.gov/reports/methods/methods.jsp. TABLE OF CONTENTS 1. EXECUTIVE SUMMARY ..................................................................................................... I 2. INTRODUCTION ................................................................................................................ 1 3. DIFFERENCES BETWEEN ICD-9-CM AND ICD-10-CM/PCS CODING SYSTEMS ........... 4 Diagnosis Coding Systems ............................................................................................. 4 Procedure Coding Systems ............................................................................................ 7 Focus Areas in the Medical and Surgical Section: Root Operations and Approaches ....10 4. LESSONS FROM DUALLY CODED DATA ........................................................................14 Differences in the ICD-9-CM and ICD-10-CM/PCS Coding Systems .............................14 Changes in Coding Rules ..............................................................................................15 Reclassification of Codes ..............................................................................................16 Coding Inconsistencies Between ICD-9-CM and ICD-10-CM/PCS ................................16 5. TOOLS TO DETERMINE CODE EQUIVALENCIES ..........................................................18 Translation Tools for Linking/Connecting ICD-9-CM and ICD-10-CM/PCS Codes .........19 General Equivalence Mappings (GEMs) ........................................................................19 Other Web-Based Tools ................................................................................................20 6. GROUPING CONDITIONS, PROCEDURES, AND COMORBIDITIES ...............................23 Assessing Sources of Information .................................................................................23 Grouping Tools for Converting ICD-10-CM/PCS Codes Into Categories ........................24 7. LONGITUDINAL ANALYSIS ..............................................................................................27 ICD-10 and Trend Analysis ............................................................................................27 Strategies ......................................................................................................................28 Comparability Ratio .......................................................................................................29 ICD-10-CM/PCS Cause of Death Transition ..................................................................30 Evidence From ICD-10 Diagnosis Codes (U.S. and International) .................................31 Other Strategies ............................................................................................................32 8. OTHER CONSIDERATIONS .............................................................................................33 Claims Payment Review Leniency Policy ......................................................................33 ICD-11 ...........................................................................................................................33 HCUP (5/20/16) Impact of ICD-10-CM/PCS 9. RESOURCES FOR RESEARCHERS ................................................................................35 Conference Proceedings and Online Webinars .............................................................35 Healthcare Cost and Utilization Project (HCUP) Software Tools ....................................35 ICD-10 Textbooks/Workbooks .......................................................................................36 ICD-10 Codebooks ........................................................................................................36 ICD-10 Software and Tools ...........................................................................................36 Peer Reviewed Journal Articles .....................................................................................37 Online Nonjournal Articles, Reports and Other Publications (From Nongovernment Agencies) ......................................................................................................................41 User Guides or Technical Reports from Government Agencies .....................................43 Working Papers .............................................................................................................45 Books ............................................................................................................................45 REFERENCES .........................................................................................................................46 APPENDIX A. MEDICAL AND SURGICAL PROCEDURE CODING: ROOT OPERATIONS AND APPROACHES ....................................................................................................................... A-1 Complete List of Root Operations ................................................................................ A-1 Complete List of Medical and Surgical Approaches ..................................................... A-6 APPENDIX B. ICD-10-PCS PROCEDURE CCS CATEGORIES THAT ARE NOT POPULATED BY ICD-10-PCS CODES ......................................................................................................... B-1 APPENDIX C. EXAMINING THE IMPACT OF ICD-10-CM/PCS IMPLEMENTATION ............. C-1 Dually Coded Discharge Dataset ................................................................................. C-1 Changes in Level of Specificity .................................................................................... C-3 Changes in Coding Rules ............................................................................................ C-8 Reclassification of Codes .......................................................................................... C-10 Coding Inconsistencies Between ICD-9-CM and ICD-10-CM/PCS ............................ C-14 Appendix References ................................................................................................ C-14 HCUP (5/20/16) Impact of ICD-10-CM/PCS INDEX OF TABLES TABLE 1. COMPARISON OF ICD-9-CM AND ICD-10-CM DIAGNOSIS CODES ...................... 5 TABLE 2. COMPARISON OF ICD-9-CM AND ICD-10-PCS PROCEDURE CODES.................. 8 TABLE 3. EXAMPLE. ICD-10-PCS 7-CHARACTER PROCEDURE CODE STRUCTURE FOR MEDICAL AND SURGICAL PROCEDURES, BREAST BIOPSY ............................................... 9 TABLE 4. EXAMPLE. ICD-10-PCS 7-CHARACTER PROCEDURE CODE STRUCTURE FOR MEDICAL AND SURGICAL PROCEDURES, RADIATION THERAPY ......................................10 TABLE 5. ICD-10-PCS ROOT OPERATION DEFINITION, EXPLANATION, AND EXAMPLES— DILATION .................................................................................................................................11 TABLE 6. COMPLETE LIST OF MEDICAL AND SURGICAL APPROACHES, FIFTH CHARACTER OF ICD-10-PCS .................................................................................................12 TABLE 7. DESCRIPTIONS FROM THE LUSSIER CONVERSION TOOLS ..............................21 TABLE 8. TOOLS FOR LINKING/CONNECTING ICD-9-CM AND ICD-10-CM/PCS CODES ...21 TABLE 9. GROUPING TOOLS FOR FINDING PATIENT COHORTS AND OTHER VARIABLES USING ICD-9-CM AND ICD-10-CM/PCS CODES ....................................................................24 INDEX OF FIGURES FIGURE 1. ICD-9-CM AND ICD-10-CM DIAGNOSIS CODING SYSTEMS ................................ 4 FIGURE 2. ICD-9-CM AND ICD-10-PCS PROCEDURE CODING SYSTEMS ........................... 7 FIGURE 3. EXAMPLE OF LONGITUDINAL CHANGE IN CODE SETS ....................................28 FIGURE 4. EXAMPLE OF COMPARABILITY RATIO ADJUSTMENT FROM ICD-10-CM/PCS TO ICD-9-CM CODES IN A LONGITUDINAL ANALYSIS .........................................................30 HCUP (5/20/16) Impact of ICD-10-CM/PCS 1. EXECUTIVE SUMMARY In October 2015 the United States transitioned to a modified version of the World Health Organization (WHO) International Classification of Diseases (ICD-10-CM/PCS), replacing the ICD-9-CM diagnosis and procedure coding system with the ICD-10-CM diagnosis coding system for most inpatient and outpatient medical encounters and the ICD-10-PCS procedure coding system for inpatient hospital procedures. This transition is expected to have a profound and direct impact on reimbursement and the delivery of medical care. However, health care researchers are expected to be affected by this transition when administrative databases become available with ICD-10-CM/PCS codes. This document is intended to summarize many of the main issues encountered by researchers when transitioning to the ICD-10-CM/PCS coding system, and summarizes tools and resources available to assist researchers with this transition. Differences Between ICD-9-CM and ICD-10-CM/PCS Coding Systems Researchers will have many more clinical codes to reference when using ICD-10-CM/PCS
Load more

Recommended publications
  • Coding for Angioplasty & Stent Procedures
    Coding for Angioplasty & Stent Procedures July 2020 Jennifer Bash, RHIA, CIRCC, RCCIR, CPC, RCC Director of Coding Education Agenda • Introduction • Definitions • General Coding Guidelines • Presenting Problems/Medical Necessity for Angioplasty & Stent • General Angioplasty & Stent Procedures • Cervicocerebral Procedures • Lower Extremity Procedures Disclaimer The information presented is based on the experience and interpretation of the presenters. Though all of the information has been carefully researched and checked for accuracy and completeness, ADVOCATE does not accept any responsibility or liability with regard to errors, omissions, misuse or misinterpretation. CPT codes are trademark and copyright of the American Medical Association. Resources •AMA •CMS • ACR/SIR • ZHealth Publishing Angioplasty & Stent Procedures Angioplasty Angioplasty, also known as balloon angioplasty and percutaneous transluminal angioplasty, is a minimally invasive endovascular procedure used to widen narrowed or obstructed arteries or veins, typically to treat arterial atherosclerosis. Vascular Stent A stent is a tiny tube placed into the artery or vein used to treat vessel narrowing or blockage. Most stents are made of a metal or plastic mesh-like material. General Angioplasty & Stent Coding Guidelines • Angioplasty is not separately billable when done with a stent • Pre-Dilatation • PTA converted to Stent • Prophylaxis • EXCEPTION-Complication extending to a different vessel • Coded per vessel • Codes include RS&I • Territories • Hierarchy General Angioplasty
    [Show full text]
  • Alternative Treatment Method for Cervical Ectopic Pregnancy Servikal Ektopik Gebelik İçin Alternatif Tedavi Yöntemi
    J Kartal TR 2016;27(2):147-149 CASE REPORT doi: 10.5505/jkartaltr.2015.065982 OLGU SUNUMU Alternative Treatment Method for Cervical Ectopic Pregnancy Servikal Ektopik Gebelik İçin Alternatif Tedavi Yöntemi Ali Emre TAHAOĞLU, Mehmet İrfan KÜLAHÇIOĞLU, Ahmet ESER, Cihan TOĞRU Diyarbakır Obstetrics and Child Health Hospital, Diyarbakır, Turkey Summary Özet Cervical ectopic pregnancy is a very rare form of ectopic Servikal ektopik gebelik, tüm ektopik gebelikler arasında çok pregnancy. Cervical ectopic pregnancy can be a cause of se- nadir rastalanan bir ektopik gebelik formudur. Servikal ektopik vere bleeding and it is associated with high morbidity and gebelik ciddi bir hemoraji nedeni olabilir. Ayrıca yüksek morbi- mortality. In recent years, many conservative methods of dite ve mortalite ile ilişkilidir. Son yıllarda fertiliteyi korumak treatment seeking to preserve fertility have been reported. amacı ile farklı birçok konservatif yaklaşım rapor edilmiştir. Presently described is case of pregnant woman at gesta- Kliniğimize yedi hafta dört gün ile uyumlu fetal kardiyak ak- tional age of 7 weeks and 4 days who was admitted to clinic tivitesi olmayan gebe vajinal kanama şikayeti ile başvurdu. with vaginal bleeding. Fetal cardiac activity was negative. Hasta yüksek servikal sütür ve Mcdonald serklaj uygulanarak Patient was successfully treated with high ligation suture başarı ile tedavi edildi. Servikal gebelik tedavisi hala tartışma and McDonald cerclage. There is no consensus yet on best konusudur. Fakat tedavi konusunda henüz kesin bir fikir birliği treatment of cervical ectopic pregnancy, but conservative bulunmamaktadır. Konservatif yaklaşım hastayı histerektomi methods can avoid major surgical procedure such as hyster- gibi büyük bir cerrahiden ve bunun getirdiği kötü sonuçlardan ectomy and its consequences.
    [Show full text]
  • Surgical Best Practices: 14-Point Plan William P
    Surgical Best Practices: 14-Point Plan William P. Adams, Jr., MD & Anand K. Deva, MBBS (Hons), MS SURGICAL BEST PRACTICES: 14-POINT PLAN William P. Adams, Jr., MD and Anand K. Deva, MBBS (Hons), MS Introduction The 14-Point Plan aims to reduce the number of bacteria present at the time of breast implant placement, thereby reducing the risk of associated infection.1 Each of these steps outlined below is backed by evidence and cumulatively have been shown to reduce the risk of capsular contracture in patients following breast implant surgery. During breast implant placement, if bacteria attach to the surface of an implant and create a biofilm over time, the biofilm becomes almost impossible to remove. If the bacterial biofilm load reaches a certain threshold it can lead to chronic inflammation and known sequelae, including infection, capsular contracture, double capsule, and breast implant-associated ALCL (BIA-ALCL).1, 2 We have performed extensive bench and clinical studies on this topic and are committed to educating plastic surgeons on proven steps that have been shown to reduce the bacterial biofilm load.1 These simple steps have been shown to decrease the risk of developing capsular contracture ten-fold.3-5 Additionally, a wealth of evidence has demonstrated a link between chronic inflammation from bacterial biofilm in the pathogenesis of BIA-ALCL, especially in textured devices where the increased surface area can result in an increased amount of bacterial biofilm.2 A meticulous procedure will help minimize the known and likely sequelae of bacterial attachment including infection and chronic biofilm, which is implicated in the pathogenesis of both capsular contracture and BIA-ALCL.
    [Show full text]
  • Resection Arthroplasty for Failed Shoulder Arthroplasty
    J Shoulder Elbow Surg (2013) 22, 247-252 www.elsevier.com/locate/ymse Resection arthroplasty for failed shoulder arthroplasty Stephanie J. Muh, MDa, Jonathan J. Streit, MDb, Christopher J. Lenarz, MDa, Christopher McCrum, BSc, John Paul Wanner, BSa, Yousef Shishani, MDa, Claudio Moraga, MDd, Robert J. Nowinski, DOe, T. Bradley Edwards, MDf, Jon J.P. Warner, MDg, Gilles Walch, MDh, Reuben Gobezie, MDi,* aCase Shoulder and Elbow Service, Case Western Reserve University School of Medicine, University Hospitals of Cleveland, Cleveland, OH, USA bDepartment of Orthopaedics, Case Western Reserve University School of Medicine, University Hospitals of Cleveland, Cleveland, OH, USA cCase Western Reserve University School of Medicine, Cleveland, OH, USA dDepartment of Orthopedic Surgery, Clinica Alemana Santiago, Santiago, Chile eOrthoNeuro, New Albany, OH, USA fFondren Orthopedic Group, Houston, TX, USA gHarvard Shoulder Service, Massachusetts General Hospital, Boston, MA, USA hCentre Orthopedique Santy, Shoulder Unit, Lyon, France iThe Cleveland Shoulder Institute, University Hospitals of Cleveland, Cleveland, OH, USA Background: As shoulder arthroplasty becomes more common, the number of failed arthroplasties requiring revision is expected to increase. When revision arthroplasty is not feasible, resection arthroplasty has been used in an attempt to restore function and relieve pain. Although outcomes data for resection arthroplasty exist, studies comparing the outcomes after the removal of different primary shoulder arthro- plasties have been limited. Materials and methods: This was a retrospective multicenter review of 26 patients who underwent resection arthroplasty for failure of a primary arthroplasty at a mean follow-up of 41.8 months (range, 12-130 months). Resection arthroplasty was performed for 6 failed total shoulder arthroplasties (TSAs), 7 failed hemiarthro- plasties, and 13 failed reverse TSAs.
    [Show full text]
  • Scarless Breast Augmentation by Dr
    Scarless Breast Augmentation By Dr. Babak Farzaneh Trans-Umbilical Breast Augmenta- naval, allowing for a virtually undetect- volume adjustment for better symmetry. tion (TUBA), more commonly known able scar - even in patients with darker The path for placement shortly as the “Belly Button Procedure”, is the skin tone. This alleviates the need for heals without visible tracts, providing a most innovative and novel approach any incision on the breast. The incision quick return to normal activity. There is in the long history of breast implant is so minimal that some have nicknamed also no need for sharp cutting or burn- surgery. It has been a long time since a the procedure “Band-Aid Breast Aug- ing of the breast tissue, which mini- new approach has allowed a multitude mentation”. (Naval piercing, if present, mizes bleeding and the need for drains; of desirable additions without signifi- is left undisturbed, and the naval ring is post- procedure numbness; and, more cant drawbacks. Endoscopic surgery has sterilized and replaced at the conclusion tangibly, reduces bruising and swelling, revolutionized medicine and surgery, of the surgery.) allowing for shorter and easier recovery. allowing operations to be performed The highly unique instruments In skilled hands, this approach through smaller incisions. Following this specially manufactured for the TUBA allows for natural and predictable results trend, breast augmentation is comple- technique allow me to implement my through a very small, hidden incision. mented immensely by the introduction artistic vision to produce a natural breast As with most unique and highly special- of the TUBA technique. shape with acceptable symmetry, and ized surgical techniques, most surgeons Using a very small incision create the desirable cleavage.
    [Show full text]
  • Core Neurosurgery
    BAYLOR SCOTT & WHITE TEXAS SPINE & JOINT HOSPITAL NEUROLOGICAL SURGERY CLINICAL PRIVILEGES NAME: ________________________________ Initial appointment Reappointment All new applicants must meet the following requirements as approved by the governing body. To be eligible to apply for core privileges in neurological surgery, the initial applicant must meet the following criteria: Successful completion of ACGME or American Osteopathic Association accredited residency in neurological surgery. Required previous experience: Applicants for initial appointment must be able to demonstrate the performance of at least 50 neurological surgical procedures, reflective of the scope of privileges requested, during the last 12 months or demonstrate successful completion of residency or fellowship within the past 12 months. Reappointment requirements: To be eligible to renew core privileges in Neurological Surgery, the applicant must meet the following maintenance of privilege criteria: Current demonstrated competence and an adequate volume of neurological surgery procedures with acceptable results, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes. Evidence of current ability to perform privileges requested is required of all applicants for renewal of privileges NEUROLOGICAL SURGERY CORE PRIVILEGES Requested: Admit, evaluate, diagnose, consult and provide nonoperative and pre-, intran, and postoperative care to patients of all ages presenting with injuries
    [Show full text]
  • Coronary Angiogram, Angioplasty and Stent Placement
    Page 1 of 6 Coronary Angiogram, Angioplasty and Stent Placement A Patient’s Guide Page 2 of 6 What is coronary artery disease? What is angioplasty and a stent? Coronary artery disease means that you have a If your doctor finds a blocked artery during your narrowed or blocked artery. It is caused by the angiogram, you may need an angioplasty (AN-jee- buildup of plaque (fatty material) inside the artery o-plas-tee). This is a procedure that uses a small over many years. This buildup can stop blood from inflated balloon to open a blocked artery. It can be getting to the heart, causing a heart attack (the death done during your angiogram test. of heart muscle cells). The heart can then lose some of its ability to pump blood through the body. Your doctor may also place a stent at this time. A stent is a small mesh tube that is placed into an Coronary artery disease is the most common type of artery to help keep it open. Some stents are coated heart disease. It is also the leading cause of death for with medicine, some are not. Your doctor will both men and women in the United States. For this choose the stent that is right for you. reason, it is important to treat a blocked artery. Angioplasty and stent Anatomy of the Heart 1. Stent with 2. Balloon inflated 3. Balloon balloon inserted to expand stent. removed from into narrowed or expanded stent. What is a coronary angiogram? blocked artery. A coronary angiogram (AN-jee-o-gram) is a test that uses contrast dye and X-rays to look at the blood vessels of the heart.
    [Show full text]
  • 2017 American College of Rheumatology/American Association
    Arthritis Care & Research Vol. 69, No. 8, August 2017, pp 1111–1124 DOI 10.1002/acr.23274 VC 2017, American College of Rheumatology SPECIAL ARTICLE 2017 American College of Rheumatology/ American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty SUSAN M. GOODMAN,1 BRYAN SPRINGER,2 GORDON GUYATT,3 MATTHEW P. ABDEL,4 VINOD DASA,5 MICHAEL GEORGE,6 ORA GEWURZ-SINGER,7 JON T. GILES,8 BEVERLY JOHNSON,9 STEVE LEE,10 LISA A. MANDL,1 MICHAEL A. MONT,11 PETER SCULCO,1 SCOTT SPORER,12 LOUIS STRYKER,13 MARAT TURGUNBAEV,14 BARRY BRAUSE,1 ANTONIA F. CHEN,15 JEREMY GILILLAND,16 MARK GOODMAN,17 ARLENE HURLEY-ROSENBLATT,18 KYRIAKOS KIROU,1 ELENA LOSINA,19 RONALD MacKENZIE,1 KALEB MICHAUD,20 TED MIKULS,21 LINDA RUSSELL,1 22 14 23 17 ALEXANDER SAH, AMY S. MILLER, JASVINDER A. SINGH, AND ADOLPH YATES Guidelines and recommendations developed and/or endorsed by the American College of Rheumatology (ACR) are intended to provide guidance for particular patterns of practice and not to dictate the care of a particular patient. The ACR considers adherence to the recommendations within this guideline to be volun- tary, with the ultimate determination regarding their application to be made by the physician in light of each patient’s individual circumstances. Guidelines and recommendations are intended to promote benefi- cial or desirable outcomes but cannot guarantee any specific outcome. Guidelines and recommendations developed and endorsed by the ACR are subject to periodic revision as warranted by the evolution of medi- cal knowledge, technology, and practice.
    [Show full text]
  • Cardiac Checklist Connecticare
    Cardiac Checklist ConnectiCare Please be prepared to provide the applicable information from the following list when requesting prior authorization for a cardiac procedure managed by Magellan Healthcare1: 1. Medical chart notes – all notes from patient chart related to the requested procedure, including patient’s current cardiac status/symptoms, cardiac factors and indications. 2. Relevant patient information, including: a. Patient age, height, weight, and BMI. b. Family history of heart problems (including relationship to member, age at diagnosis, type of event, etc.). c. Medical history (e.g. diabetes, hypertension, stroke, arrhythmia, etc.). d. Cardiac risk factors. e. Previous cardiac treatments, surgeries or interventions (medications, CABG, PTCA, stent, heart valve surgery, pacemaker/defibrillator insertion, surgery for congenital heart disease, etc.). f. Problems with exercise capacity (orthopedic, pulmonary, or peripheral vascular disease; distance, heart rate). 3. Diagnostic or imaging reports from previous tests (exercise stress test, echocardiography, stress echocardiography, MPI, coronary angiography, etc.). a. For pacemaker or Implantable Cardioverter Defibrillator (ICD) requests, include EKG and/or telemetry strips showing bradycardia, EKG showing conduction abnormalities, EP study report, and/or tilt table test report, if applicable. b. For cardiac resynchronization therapy requests, include left ventricular function test report indicating LVEF, documentation of CHF symptoms and NYHA class and/or 12-Lead EKG showing QRS width, if applicable. c. For cardiac catheterization requests, include EKG results showing relevant changes, left ventricular function test reports, documentation of recent ejection fraction, etc. d. Cardiac catheterization requests also require the submission of digital images (e.g. DICOM files) from previous procedures. The digital image from a previous MPI, Stress Echocardiography, Heart PET or other cardiac catheterization is considered to be relevant and necessary clinical information.
    [Show full text]
  • EARLY DETECTION Breast Health Awareness and Clinical Breast Exam
    EARLY DETECTION Breast Health Awareness and Clinical Breast Exam Knowledge Summary EARLY DETECTION Breast Health Awareness and Clinical Breast Exam INTRODUCTION KEY SUMMARY Early diagnosis of breast cancer begins with the establish- Early detection programs ment of programs to improve early detection of symptomatic ¬ Early diagnosis of breast cancer can improve survival, lower women, or women with breast lumps that patients and their morbidity and reduces the cost of care when followed by a providers can feel. Early recognition of symptoms and accu- prompt diagnosis and effective treatment. rate diagnosis of breast cancer can result in cancers being diagnosed at earlier stages when treatment is more feasible, ¬ An effective early diagnosis program includes: affordable and effective. This requires that health systems √ Breast health awareness education. have trained frontline personnel who are able to recognize the √ Reducing barriers to accessing care. signs and symptoms of breast abnormalities for both benign √ Clinical breast exam (CBE) performed by primary care breast issues as well as cancers, perform clinical breast exam providers. (CBE) and know the proper referral protocol when diagnostic √ Timely diagnosis for all women found to have abnormal workup is warranted. Women who can identify breast abnor- findings and timely treatment for all women proven by malities, who have timely access to health clinical evaluation, tissue diagnosis to have breast cancer. diagnosis and treatment and who are empowered to seek this √ If supported by evidence, a quality screening mammogra- care are more likely to be diagnosed at an earlier stage (see phy program performed in a cost-effective, resource-sus- Planning: Improving Access to Breast Cancer Care).
    [Show full text]
  • Breast Scintimammography
    CLINICAL MEDICAL POLICY Policy Name: Breast Scintimammography Policy Number: MP-105-MD-PA Responsible Department(s): Medical Management Provider Notice Date: 11/23/2020 Issue Date: 11/23/2020 Effective Date: 12/21/2020 Next Annual Review: 10/2021 Revision Date: 09/16/2020 Products: Gateway Health℠ Medicaid Application: All participating hospitals and providers Page Number(s): 1 of 5 DISCLAIMER Gateway Health℠ (Gateway) medical policy is intended to serve only as a general reference resource regarding coverage for the services described. This policy does not constitute medical advice and is not intended to govern or otherwise influence medical decisions. POLICY STATEMENT Gateway Health℠ does not provide coverage in the Company’s Medicaid products for breast scintimammography. The service is considered experimental and investigational in all applications, including but not limited to use as an adjunct to mammography or in staging the axillary lymph nodes. This policy is designed to address medical necessity guidelines that are appropriate for the majority of individuals with a particular disease, illness or condition. Each person’s unique clinical circumstances warrant individual consideration, based upon review of applicable medical records. (Current applicable Pennsylvania HealthChoices Agreement Section V. Program Requirements, B. Prior Authorization of Services, 1. General Prior Authorization Requirements.) Policy No. MP-105-MD-PA Page 1 of 5 DEFINITIONS Prior Authorization Review Panel – A panel of representatives from within the Pennsylvania Department of Human Services who have been assigned organizational responsibility for the review, approval and denial of all PH-MCO Prior Authorization policies and procedures. Scintimammography A noninvasive supplemental diagnostic testing technology that requires the use of radiopharmaceuticals in order to detect tissues within the breast that accumulate higher levels of radioactive tracer that emit gamma radiation.
    [Show full text]
  • Neurosurgery
    KALEIDA HEALTH Name ____________________________________ Date _____________ DELINEATION OF PRIVILEGES - NEUROSURGERY All members of the Department of Neurosurgery at Kaleida Health must have the following credentials: 1. Successful completion of an ACGME accredited Residency, Royal College of Physicians and Surgeons of Canada, or an ACGME equivalent Neurosurgery Residency Program. 2. Members of the clinical service of Neurosurgery must, within five (5) years of appointment to staff, achieve board certification in Neurosurgery. *Maintenance of board certification is mandatory for all providers who have achieved this status* Level 1 (core) privileges are those able to be performed after successful completion of an accredited Neurosurgery Residency program. The removal or restriction of these privileges would require further investigation as to the individual’s overall ability to practice, but there is no need to delineate these privileges individually. PLEASE NOTE: Please check the box for each privilege requested. Do not use an arrow or line to make selections. We will return applications that ignore this directive. LEVEL I (CORE) PRIVILEGES Basic Procedures including: Admission and Follow-Up Repair cranial or dural defect or lesion History and Physical for diagnosis and treatment plan* Seizure Chest tube placement Sterotactic framed localization of lesion Debride wound Sterotactic frameless localization Endotracheal intubation Transsphenoidal surgery of pituitary lesion Excision of foreign body Trauma Insertion of percutaneous arterial
    [Show full text]