Medical Necessity, LMRP Rules And ABN Rules

This rule set provides conditions that are:

• applied to Medicare and other insurances.
• applied to basic CPT/Diagnosis based LMRP calculations.
• applied to utlize combined multiple diagnosis groups.

This rule set does not apply to any Bill To that is not related to insurance, such as “Client” or “Your Office”.

The medical necessity and LMRP rule set is implemented in the rules engine through both permissions and maintenance.

See the APPENDIX - Medical Necessity, LMRP and ABN Tables Relationship in the Appendix for the relationships between the FO_Ins, FO_Users, FO_CPTReview and FO_CPTReviewCombinedDx tables for this rule set.

To activate this rule set, you must:

1. Assign permission abnprint to a user group.
2. Enter data into the FO_Ins table:

   See FO_INS for more information about field definitions and allowed values.

   • ReviewCarrier: Carrier code that this insurance code is associated with for medical necessity rules. Must be exactly the same as the FO_CPTReview.Carrier field value.
   • UseABN: Must be set to 1. Qualifies this insurance for LMRP checking.
   • ReviewCPTs: All CPT codes that apply to this insurance to check medical necessity. This set of codes are the only CPT codes checked for medical necessity and are cross-referenced to the FO_CPTReview table.
   • MedNecessityFormCodes: All form codes for the medical necessity, ABN, related forms available for printing. Skip this field to default to |ABNENGLISH|ABNSPANISH|

3. Enter data into the FO_Users table:

   See FO_Users for more information about field definitions and allowed values.

   • MedicareRegion: The Medicare region is used as an identifying value during LMRP rules processing. It is also used to match the user to the information in the FO_CPTReview table using the FO_CPTReview.Region field value.

4. Enter data into the FO_CPTReview table:

   See FO_CPTReview for more information about field definitions and allowed values.

   • Enter a record for each CPT and ICD code pair for each applicable insurance carrier and Medicare region into the FO_CPTReview table. This data updates the LMRP and NCD rules and is linked to both user settings and insurance. In each record, provide values for:
     • CPT: A single valid CPT code.
     • ICD: A single valid ICD code.
     • Carrier: A single valid insurance carrier code. This represents the insurance used for this CPT/ICD pair. Must be exactly the same as the FO_Ins.ReviewCarrier field.
     • Region: A single valid Medicare region which represents the region used for this CPT/ICD pair.

 

Basic LMRP Rule

To specifically use the basic LMRP rule, you must also:

1. Create a default rule, or record, in the FO_CPTReview table for each CPT code for the insurance carrier. The record must have specific values for:
   • ICD: Enter |ALL|
   • Reason: Represents the result of this rule evaluation, enter either D, E, F, or P. Enter the result reason that is most common for this CPT code. A result record will be created when the test fails LMRP checking. (does that mean that a record will be created? If so, in what table and how is it retrieved/displayed/reported?)

     Reason D: specifies a diagnosis failure.

     Reason E: specifies an experimental test failure.

     Reason F: specifies a frequency failure. Requires that a frequency count and duration in days is specified.

     Reason P: specifies that a diagnosis is payable.

2. Create a rule, or record, in the FO_CPTReview table for each exception to the default rule for each CPT/ICD pair related to this carrier and each CPT code in this list. (How does that manifest? Are there specific values for certain fields?)

 

Supporting Diagnosis Rule

To specifically use the supporting diagnosis rule, you must also:

1. Create a default rule, or record, in the FO_CPTReview table for the insurance carrier and for each CPT code that will have support diagnoses. The record must have specific values for:
   • ICD: Enter |ALL|W
   • Reason: Represents the result of this rule evaluation, enter either 1 or 2. Enter the result reason that is most common for this CPT code. The test will fail LMRP checking for all conditions not defined in the FO_CPTReviewCombinedDx table. A result record will be created when the test fails LMRP checking.

     Reason 1: specifies a diagnosis failure that requires supporting diagnosis combinations.

     Reason 2: specifies that a frequency rule will be applied that requires supporting diagnosis combinations.

   Note: The FO_CTPReview table must only contain the default rule.

2. Create an exception rule, or record, in the FO_CPTReviewCombinedDx table for each exception to the default rule created above.

   The frequency and duration values in the default rule are used in the calculation.

   To create these rules, you must enter data into the FO_CPTReviewCombinedDx table:

   See FO_CPTReviewCombinedDx for more information about field definitions and allowed values.

• Carrier: Enter the insurance carrier code.
• Region: Enter the Medicare region.
• ChargeTo: Informational Only. (then why even mention it? Or just say “Skip this entry”. Does it get filled in somehow with information? If so, what might been seen in this field and how did it get there?)
• CPT: Enter a single valid CPT code.
• StartDate: Start date/time for this exception rule. Format MM/DD/YYYY HH:MM:SS. If the actual start date is unknown, enter ‘01/01/1900 00:00’, seconds are not required. [The FAST db schema says the default is “1/1/1900 12:00:00 AM”. But it doesn’t seem the seconds nor the AM/PM are required. Also could we just say “Skip this entry to default to ‘01/01/1900 00:00’” instead of telling the reader to type in that value. Also seems that EndDate is on 24-hr format so the AM/PM is irrelevant.]
• EndDate: End date/time for this exception rule. Format MM/DD/YYYY HH:MM:SS. If the actual end date is unknown, enter ‘12/31/2099 23:59, seconds are not required. [See comment/?? above re the FAST db schema]
• DiagnosisCode: A comma delimited set of valid diagnosis codes. Each code is a payable condition. (is this correct?)
• DiagCodingMethod: Skip this entry. Future Use. (is this correct?)

Note: A maximum of four FO_CPTReviewCombinedDx records can be created for each CPT code. (How is this enforced?)

 

ABN Rules

Assign permission abnprint to a user group for users to be able to see and print ABN forms.

The ABN form is formatted to allow tests with different messages to appear on separate lines on the form. Each test can have a distinct message as defined in the FO_Tests table in the ABN fields for English and Spanish for the three main failure types; frequency, diagnosis, and experimental. If no specific message is defined, the default message is printed.

Cancelled tests will be blocked from ABN/medical necessity form printing.

See FO_Tests for more information about field definitions and allowed values.