FO_CPTReview

This table contains medical necessity rules.

Each record represents a CPT code and ICD code pair. Default records can be created representing all ICD codes for a single CPT code to speed entries. The rules allow for diagnosis, frequency, and experimental test definitions

A default record representing all ICD codes for a test may be created by using the keyword 'ALL' as an ICD field value.

The system allows you to define CPT/ICD pairs based on carrier and region.

The carrier represents the company that is the originator of each rule set. The carrier links the entry to the FO_Ins table and the particular insurance code that mandates this rule. The region field assigns the entry to a particular user name so you can specify sub-categories in the rules if required by the user creating the order.

 

Field Type Notes

Carrier

varchar(50)

Code for the insurance carrier FI to which this CPT ICD pair will be assigned.

Enter a valid insurance carrier code.

(what does FI mean and is it really needed here?)

Region

int

Region.

Enter a valid region as defined in the FO_Users table.

CPT

varchar(10)

CPT code.

Enter a valid CPT code.

ICD

varchar(10)

ICD code.

Enter a valid ICD code as defined in the FO_ICD9 table.

Enter 'ALL' to indicate that this is a default condition for this CPT code.

If 'ALL', make sure there is only one default record for this CPT code.

Reason

varchar(3)

Represents the result of this rule evaluation.

Enter an allowed value.

Allowed values:

P = this ICD/CPT pair is payable

D = this ICD/CPT pair represents a diagnosis failure that should result in an ABN form

F = represents a frequency failure based on following fields in this table

E = to cause the pair to fail as an experimental test

1 = indicates a diagnosis failure type rule

2 = indicates a frequency failure type rule

Entries 1 or 2 require subsequent definitions in the FO_CPTReviewCombinedDX table for reviewing a CPT against multiple required diagnoses.

Freq_Ct

int

Number of tests for a patient in the predefined time frame, Freq_Dur, that should cause a frequency failure.

Enter an integer for the number of tests.

Freq_Dur

varchar(10)

Number of days in the time frame for the frequency count, Freq_Ct.

Enter an integer for the number of days.

CPTReview_ID

decimal(18, 0)

ID field, a counter. Unique

CreateDate

Datetime

System timestamp when record is created.

Informational

EditDate

datetime

System timestamp when record is edited.

Informational

LastUpdate

datetime

System timestamp when record was last updated.

Informational

DiagCodingMethod

varchar(50)

*** NEED DEFINITION ***