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 *** |