app.py

import streamlit as st

st.set_page_config(layout="wide")

st.markdown("""

## Service Code Ranges:

1. Organ Transplant
   - CPT Code Range: 50300-50380
   - Rules for Required Evidence of Medical Necessity: Diagnosis, waiting list, physician referral

2. Spinal Fusion Surgery
   - CPT Code Range: 22532-22812
   - Rules for Required Evidence of Medical Necessity: Diagnosis, conservative treatment history, physician referral

3. Bariatric Surgery
   - CPT Code Range: 43644-43775
   - Rules for Required Evidence of Medical Necessity: BMI, documented weight loss attempts, physician referral, psychological evaluation

4. Joint Replacement Surgery
   - CPT Code Range: 27130-27447
   - Rules for Required Evidence of Medical Necessity: Diagnosis, conservative treatment history, physician referral

5. Chemotherapy
   - CPT Code Range: 96401-96549
   - Rules for Required Evidence of Medical Necessity: Cancer diagnosis, treatment plan, medication, dosage, and frequency

6. Radiation Therapy
   - CPT Code Range: 77261-77799
   - Rules for Required Evidence of Medical Necessity: Cancer diagnosis, treatment plan, physician referral

7. Cardiac Surgery
   - CPT Code Range: 33010-33999
   - Rules for Required Evidence of Medical Necessity: Diagnosis, conservative treatment history, physician referral

8. Dialysis
   - CPT Code Range: 90935-90999
   - Rules for Required Evidence of Medical Necessity: Diagnosis of kidney disease, treatment plan, physician referral

9. Gastrointestinal Surgery
   - CPT Code Range: 43620-44979
   - Rules for Required Evidence of Medical Necessity: Diagnosis, conservative treatment history, physician referral

10. Advanced Imaging Services
    - CPT Code Range: 70450-72159 (CT), 70540-72198 (MRI)
    - Rules for Required Evidence of Medical Necessity: Clinical history, prior relevant imaging, symptoms justification

11. Interventional Radiology
    - CPT Code Range: 37220-37235
    - Rules for Required Evidence of Medical Necessity: Diagnosis, conservative treatment history, physician referral

12. Sleep Study
    - CPT Code Range: 95800-95811
    - Rules for Required Evidence of Medical Necessity: Documented sleep disorder symptoms, sleep diary, physician referral

13. Infusion Therapy
    - CPT Code Range: 96360-96549
    - Rules for Required Evidence of Medical Necessity: Diagnosis, medication, dosage, frequency, and duration

14. Pain Management
    - CPT Code Range: 64400-64530
    - Rules for Required Evidence of Medical Necessity: Diagnosis, conservative treatment history, treatment plan

15. Cardiac Stress Test
    - CPT Code Range: 93015-93018
    - Rules for Required Evidence of Medical Necessity: Documented symptoms, cardiac risk factors, physician referral

16. Pulmonary Function Test
    - CPT Code Range: 94010-94799
    - Rules for Required Evidence of Medical Necessity: Documented respiratory issues, physician referral

17. Physical Therapy
    - CPT Code Range: 97110-97546
    - Rules for Required Evidence of Medical


## Services

| Service Type              | CPT Code | Rules for Required Evidence of Medical Necessity                       |
|---------------------------|----------|-----------------------------------------------------------------------|
| Mental Health Services    | 90791    | Physician referral, initial evaluation, treatment plan                |
| Eye Examination           | 92002    | Documented vision problems, physician referral                        |
| Hearing Test              | 92502    | Documented hearing problems, physician referral                       |
| Sinus CT Scan             | 31231    | Clinical history, prior relevant imaging, symptoms justification      |
| Dental Surgery            | 00100    | Diagnosis, treatment plan, physician referral                         |
| Thyroidectomy             | 60210    | Diagnosis, conservative treatment history, physician referral         |
| Cardiac Stress Test       | 93015    | Documented symptoms, cardiac risk factors, physician referral         |
| Pulmonary Function Test   | 94002    | Documented respiratory issues, physician referral                     |
| Upper GI Endoscopy        | 43200    | Documented gastrointestinal issues, physician referral                |
| Liver Biopsy              | 47000    | Diagnosis, treatment plan, physician referral                         |
| Kidney Stone Removal      | 50010    | Diagnosis, conservative treatment history, physician referral         |
| Adrenal Gland Surgery     | 60500    | Diagnosis, conservative treatment history, physician referral         |
| Pancreatic Surgery        | 48100    | Diagnosis, conservative treatment history, physician referral         |
| Splenectomy               | 38100    | Diagnosis, conservative treatment history, physician referral         |
| Colonoscopy               | 44140    | Documented gastrointestinal issues, physician referral                |
| Cystoscopy                | 51700    | Documented urinary issues, physician referral                         |
| Hysterectomy              | 58150    | Diagnosis, conservative treatment history, physician referral         |
| Nerve Conduction Study    | 95900    | Documented peripheral neuropathy, physician referral                  |
| Skin Biopsy               | 96910    | Documented skin lesions, physician referral                           |
| Physical Therapy          | 97110    | Physician referral, initial evaluation, treatment plan                |




## Main Headings - Policy or Plan

| Main Heading                         | Policy or Plan                                                       |
|--------------------------------------|----------------------------------------------------------------------|
| Service Code Grouping                | Group codes based on service type or specialty                       |
| Listing for PA Medical Necessity     | List of services requiring prior authorization for medical necessity |
| Approval Criteria                    | Guidelines and criteria for approving prior authorization requests   |
| Required Evidence of Medical Necessity| Documentation needed to support medical necessity for PA requests     |
| Service Codes (CPT)                  | Specific service codes that require prior authorization               |

## Service Code Groupings:

| Service Type          | CPT Code | Rules for Required Evidence of Medical Necessity                            |
|-----------------------|----------|----------------------------------------------------------------------------|
| Physical Therapy      | 97001    | Physician referral, initial evaluation, treatment plan                     |
| Occupational Therapy  | 97165    | Physician referral, initial evaluation, treatment plan                     |
| Speech Therapy        | 92507    | Physician referral, initial evaluation, treatment plan                     |
| MRI Brain             | 70551    | Clinical history, prior relevant imaging, symptoms justification           |
| CT Scan Abdomen       | 74150    | Clinical history, prior relevant imaging, symptoms justification           |
| Sleep Study           | 95810    | Documented sleep disorder symptoms, sleep diary, physician referral        |
| Cardiac Stress Test   | 93015    | Documented symptoms, cardiac risk factors, physician referral              |
| Echocardiogram        | 93306    | Documented symptoms, cardiac risk factors, physician referral              |
| Home Health Services  | 99341    | Physician referral, homebound status, plan of care                         |
| Infusion Therapy      | 96365    | Diagnosis, medication, dosage, frequency, and duration                     |
| Pain Management       | 64490    | Diagnosis, conservative treatment history, treatment plan                  |
| Bariatric Surgery     | 43644    | BMI, documented weight loss attempts, physician referral, psychological evaluation |
| Joint Replacement     | 27447    | Diagnosis, conservative treatment history, physician referral              |
| Spinal Fusion         | 22630    | Diagnosis, conservative treatment history, physician referral              |
| Outpatient Surgery    | 10060    | Diagnosis, procedure necessity justification, physician referral           |
| Allergy Testing       | 86003    | Documented allergy symptoms, treatment history, physician referral         |
| Chemotherapy          | 96413    | Cancer diagnosis, treatment plan, medication, dosage, and frequency        |
| Radiation Therapy     | 77412    | Cancer diagnosis, treatment plan, physician referral                       |
| Dialysis              | 90935    | Diagnosis of kidney disease, treatment plan, physician referral            |
| Inpatient Hospitalization | 99223 | Medical necessity for admission, diagnosis, treatment plan, physician referral |




## EDI Sample with All DX and Services


EDI:


ISA*00*          *00*          *ZZ*EMRSENDER      *ZZ*RECEIVER       *230504*1345*^*00501*000000001*0*P*:~
GS*HS*EMRSENDER*RECEIVER*20230504*1345*1*X*005010X221A1~
ST*278*0001~
BHT*0078*11*100012345*20230504*1345~
HL*1**20*1~
NM1*X3*2*RECEIVER*****46*123456789~
HL*2*1*21*1~
NM1*1P*2*DOE*JANE****46*987654321~
HL*3*2*19*1~
TRN*1*100012345*987654321~
UM*HS*100012345*987654321~
HCR*A*1*ZZZ001~
HI*BF:7295:::3~
HI*BF:72148:::1~
HI*BF:72156:::1~
HI*BF:72158:::1~
HI*BF:S72.0:::1~
HI*BF:M16.10:::1~
SE*13*0001~
GE*1*1~
IEA*1*000000001~


## ADT A08 Event

ADT:


MSH|^~\&|EMRSENDER|FACILITY_A|RECEIVER|FACILITY_A|20230504||ADT^A08^ADT_A01|0001|P|2.5
EVN|A08|20230504|||BROWN^SARAH|20230504
PID|||100012345^^^FACILITY_A^MRN||PATIENT^JOHN^M||||||||||||100012345
PV1||I|FLOOR^1001^1^FACILITY_A||||987654321^DOE^JANE|||||||||||||||||||||||||20230504
PV2|||^^^FACILITY_A|||||||||||||||||||||||||||||||||||||3
PV3|3|ICD10|S72.0^M16.10^Z96.649
PV4||O
AL1|1|||^^^72148^72156^72158
DG1|1|ICD10|S72.0|Fracture of neck of femur|20230504
DG1|2|ICD10|M16.10|Bilateral primary osteoarthritis of hip|20230504
ZCD|3|CPT|72148^72156^72158


## Clinical Document

CCD:

Clinical Document

**Patient:** John Patient

**Date:** 2023-05-04

**Chief Complaint:**
John experienced a fall, resulting in a **hip injury**. The patient complains of severe pain and difficulty in walking.

**History of Present Illness:**
The patient has a history of **bilateral primary osteoarthritis of the hip (M16.10)**. The fall exacerbated the existing condition, causing **fracture of the neck of femur (S72.0)**.

**Physical Examination:**
Upon examination, the patient had severe pain, limited range of motion, and swelling of the affected hip. Imaging studies were ordered to assess the extent of the damage.

**Imaging Studies:**
1. **MRI of the pelvis (CPT 72148)**
2. **MRI of the bilateral hips (CPT 72156)**
3. **MRI of the bilateral femurs (CPT 72158)**

The MRI scans revealed significant damage to the hip joint, confirming the **fracture of the neck of femur (S72.0)** and worsening of the **bilateral primary osteoarthritis of the hip (M16.10)**.

**Assessment:**
Based on the clinical findings and imaging results, it is evident that the patient requires immediate surgical intervention to repair the hip joint and prevent further complications.

**Plan:**
1. Admit the patient to the hospital for surgical treatment.
2. Perform an emergent **hip replacement surgery (Z96.649)** to repair the hip joint and restore function.
3. Postoperative rehabilitation and physical therapy to regain strength and mobility.

**Medical Necessity:**
The emergent hip replacement surgery is medically necessary due to the following factors:
- Severe pain and functional impairment caused by the **fracture of the neck of femur (S72.0)**
- Worsening of pre-existing **bilateral primary osteoarthritis of the hip (M16.10)**
- High risk of complications if left untreated

Based on the clinical evidence, the patient's condition warrants immediate surgical intervention to alleviate pain, restore function, and prevent further complications. The surgery is deemed medically necessary to improve the patient's quality of life and long-term prognosis.

**Attending Physician:** Dr. Sarah Brown

## Note and Summary Index by Code Type

| Code Value | Code Description                               | Code Type       | Decision Relevance                 | Additional Information                      |
|------------|-----------------------------------------------|-----------------|------------------------------------|---------------------------------------------|
| 7295       | Authorization and Referral Services           | EDI             | Required for authorization         |                                             |
| 72148      | MRI of the pelvis                             | CPT             | Medical necessity for imaging      |                                             |
| 72156      | MRI of the bilateral hips                     | CPT             | Medical necessity for imaging      |                                             |
| 72158      | MRI of the bilateral femurs                   | CPT             | Medical necessity for imaging      |                                             |
| S72.0      | Fracture of the neck of femur                 | ICD10           | Diagnosis, treatment decision      |                                             |
| M16.10     | Bilateral primary osteoarthritis of the hip   | ICD10           | Diagnosis, treatment decision      |                                             |
| Z96.649    | Presence of unspecified artificial hip joint  | ICD10           | Procedure, treatment decision      |                                             |
| A08        | Update Patient Information                    | ADT Event       | Patient update after surgery       |                                             |
| 72148      | MRI of the pelvis                             | ZCD             | Diagnostic code for imaging        |                                             |
| 72156      | MRI of the bilateral hips                     | ZCD             | Diagnostic code for imaging        |                                             |
| 72158      | MRI of the bilateral femurs                   | ZCD             | Diagnostic code for imaging        |                                             |
| 987654321  | Dr. Jane Doe - Initial Attending Physician    | NPI             | Patient care provider              | Taxonomy: 207Q00000X (Family Medicine)      |
| 123456789  | Dr. Robert Smith - Second Attending Physician | NPI             | Patient care provider              | Taxonomy: 207Q00000X (Family Medicine)      |
| 000000001  | Dr. Sarah Brown - Surgeon                     | NPI             | Patient care provider, surgery     | Taxonomy: 207XS0106X (Orthopedic Surgery)   |
| 555444333  | Facility A                                    | Facility NPI    | Patient care facility              | Name: Facility A                            |
|            |                                               | Facility Address|                                    | Address: 123 Main St, City, State, Zip Code |
| J7325      | Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection, 1 mg | HCPCS | Medication used during treatment |        |
| Q4081      | Injection, dexamethasone sodium phosphate, 1 mg | HCPCS           | Medication used during treatment |                                             |
| 99238      | Hospital discharge day management, 30 minutes or less | CPT      | Follow-up plan                    |                                             |
| 99239      | Hospital discharge day management, more than 30 minutes | CPT      | Follow-up plan                    |                                             |



""")