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import streamlit as st
st.set_page_config(layout="wide")
st.markdown("""
📊Costly Condition 📑EDI 278A Request 📨ADT Message Type 🏥ADT Event 📄Clinical Document Example
🩸Diabetes: “Diabetes Mellitus”💉AND (“Patient Admission” OR “Patient Discharge”)👩⚕️ADT^A01 💊PATIENT ADMIT/DISCHARGE 📝Discharge Summary
❤️Heart Disease: “Heart Diseases”❤️AND (“Patient Admission” OR “Patient Discharge”)👩⚕️ADT^A01 💊PATIENT ADMIT/DISCHARGE 📝Discharge Summary
😔Anxiety & Depression: “Depression” or “Anxiety”😢AND (“Patient Admission” OR “Patient Discharge”)👩⚕️ADT^A01💊PATIENT ADMIT/DISCHARGE 📝Discharge Summary
🦴Musculoskeletal Disorders: “Musculoskeletal Diseases”🦴AND (“Patient Admission” OR “Patient Discharge”)👩⚕️ADT^A01 💊PATIENT ADMIT/DISCHARGE 📝Discharge Summary
🤔What are MeSH terms❓ MeSH terms help sort articles in PubMed by topic. Here are the MeSH terms used for each costly condition:
1. 🩸Diabetes: “Diabetes Mellitus”💉- high blood sugar levels disease
2. ❤️Heart Disease: “Heart Diseases”❤️- troubles in the heart
3. 😔Anxiety & Depression: “Depression” or “Anxiety”😢- feelings of sadness, worry and fear
4. 🦴Musculoskeletal Disorders: “Musculoskeletal Diseases”🦴- problems in bones, muscles, and joints.
Costly Condition EDI 278A Request ADT Message Type ADT Event Clinical Document Example
Diabetes “Diabetes Mellitus”[MeSH Terms] AND (“Patient Admission”[Mesh] OR “Patient Discharge”[Mesh]) ADT^A01 PATIENT ADMIT/DISCHARGE Discharge Summary
Heart Disease “Heart Diseases”[MeSH Terms] AND (“Patient Admission”[Mesh] OR “Patient Discharge”[Mesh]) ADT^A01 PATIENT ADMIT/DISCHARGE Discharge Summary
Anxiety & Depression “Depression”[MeSH Terms] OR “Anxiety”[MeSH Terms] AND (“Patient Admission”[Mesh] OR “Patient Discharge”[Mesh]) ADT^A01 PATIENT ADMIT/DISCHARGE Discharge Summary
Musculoskeletal Disorders “Musculoskeletal Diseases”[MeSH Terms] AND (“Patient Admission”[Mesh] OR “Patient Discharge”[Mesh]) ADT^A01 PATIENT ADMIT/DISCHARGE Discharge Summary
explain the mesh terms for each
- MeSH terms are a way of categorizing and organizing articles in PubMed based on their subject matter. The MeSH terms used for each costly condition in the table are as follows:
1. Diabetes: “Diabetes Mellitus” is a MeSH term used to describe a group of metabolic diseases characterized by high blood sugar levels.
2. Heart Disease: “Heart Diseases” is a MeSH term used to describe a variety of conditions that affect the heart.
3. Anxiety & Depression: “Depression” and “Anxiety” are separate MeSH terms used to describe mood disorders characterized by persistent feelings of sadness and/or anxiety.
4. Musculoskeletal Disorders: “Musculoskeletal Diseases” is a MeSH term used to describe a variety of conditions that affect the bones, muscles, and joints.
Costly Condition EDI 278A Request ADT Message Type ADT Event Clinical Document Example
Diabetes
Heart Disease
Anxiety & Depression
Musculoskeletal Disorders
ISA*00* *00* *ZZ*SENDERID *ZZ*RECEIVERID *220505*1200*^*00501*000000001*0*P*:~
GS*HI*SENDERID*RECEIVERID*20220505*1200*1*X*005010X217~
ST*278*0001~
BHT*0078*11*10001234*20220505*1200*16~
HL*1**20*1~
NM1*X3*2*PAYER NAME*****PI*PAYERID~
HL*2*1*21*1~
NM1*1P*2*PROVIDER NAME*****XX*PROVIDER NPI~
HL*3*2*22*1~
NM1*IL*1*LAST NAME*FIRST NAME****MI*MEMBERID~
TRN*1*REFNUM*ABCDEFGHIJ~
UM*HS*I*1~
HCR*A3*APPROVAL NUMBER~
DTP*472*D8*20220506~
HI*ABK:DIAGNOSIS CODE~
MSG*Prior authorization approved for the requested service.~
SE*13*0001~
GE*1*1~
IEA*1*000000001~
Description of each part:
ISA: Interchange Control Header segment, contains sender and receiver information.
GS: Functional Group Header segment, contains functional group information.
ST: Transaction Set Header segment, marks the start of the transaction set.
BHT: Beginning of Hierarchical Transaction segment, contains transaction set information.
HL: Hierarchical Level segment, used to define hierarchical structure.
NM1: Name segment, used to identify entities such as payer, provider, and patient.
TRN: Trace segment, contains reference number for the transaction.
UM: Health Care Services Review segment, contains review information.
HCR: Health Care Services Review segment, contains review decision information.
DTP: Date/Time Qualifier segment, contains relevant dates.
HI: Health Care Information Codes segment, contains diagnosis codes.
MSG: Message Text segment, contains human-readable messages.
SE: Transaction Set Trailer segment, marks the end of the transaction set.
GE: Functional Group Trailer segment, marks the end of the functional group.
IEA: Interchange Control Trailer segment, marks the end of the interchange.
For the four high-cost service packages (Diabetes, Heart Disease, Anxiety & Depression, Musculoskeletal Disorders), the diagnosis list and clinical evidence for prior authorization would be included in the HI and MSG segments, respectively. The diagnosis codes would be specified in the HI segment, while the clinical evidence and any additional information would be provided in the MSG segment.
# In Context Learning:| Costly Condition | EDI 278A Request | ADT Message Type | ADT Event | Clinical Document Example |
|---------------------------|-----------------------------------|------------------|-----------|----------------------------------------------|
| Diabetes | REF|1234567890|DOE^JOHN||20230505120000|19730101|M|123 Main St^^Anytown^NC^12345^^^||(555)555-1234|(555)555-5678||123456789|999-99-9999|||||||||| | ADT^A01 | A01 | Admitting a patient to the hospital for diabetes management |
| Heart Disease | RQ|111111|20181214|20181220|Acme Health Plan|1234 1st Street|Anytown|NC|12345| | | | | | | | ADT^A01 | A01 | Admitting a patient to the hospital for heart surgery |
| Anxiety & Depression | REF|1234567890|DOE^JOHN||20230505120000|19730101|M|123 Main St^^Anytown^NC^12345^^^||(555)555-1234|(555)555-5678||123456789|999-99-9999|||||||||| | ADT^A01
| Costly Condition | EDI 278A Request | ADT Message Type | ADT Event | Clinical Document Example |
|---------------------------------|-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------|-----------------|-----------|-------------------------------------------------------------------------------------------------------------------------------------------|
| Diabetes | | | |
| | | | |
| Heart Disease | | | |
| | | | |
| Anxiety & Depression | | | |
| | | | |
| Musculoskeletal Disorders | | | |
| | | | |
| Patient Information Update | MSH|^~\&|SendingApp|SendingFac|ReceivingApp|ReceivingFac|20230505120000||ADT^A08^ADT_A01|1234567|P|2.3|||||||||EVN|A08|20230505120000||||PID|1||123456789^^^MRN^MR||DOE^JOHN||20230505120000|M||||||||||||||||||PV1|1||||||||||||||||||| |
| | PRD|FR|SendingApp|SendingFac||||||| | ADT^A08 | A08 | Updating patient's demographic information |
| Diabetes | 0028|030| |Initial Claim Request |
| | CLM|123456789012345|10000| |17|01|Y| |7|Y|Y|Y|Y| | | |20120328| | | |0000000| |0000000|0000000| |
| Heart Disease | 0081|029| |Treatment Plan Request |
| | RQ|111111|20181214|20181220|Acme Health Plan|1234 1st Street|Anytown|NC|12345| | | | | | | |
| Anxiety & Depression | 0160|017| |Referral Request |
| | REF|1234567890|DOE^JOHN||20220505120000|19730101|M|123 Main St^^Anytown^NC^12345^^^||(555)555-1234|(555)555-5678||123456789|999-99-9999|||||||||| | | ADT^A01 | A01 | Admitting a patient to the hospital for a planned procedure |
| Musculoskeletal Disorders | 0450|012| |Authorization Request |
| | PRV|PC|1234 1st Street|Anytown|NC|12345|US|5555555555| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
## Diabetes Clinical Document (for Teaching Purposes only)
Patient: John Doe
DOB: 01/01/1960
Diagnosis: Diabetes Mellitus Type 2 (ICD-10 E11.9)
Medications: Metformin 1000mg PO BID, Insulin glargine 20 units subcutaneous daily
Assessment:
Mr. Doe's blood glucose levels have been well controlled with his current medication regimen. His most recent A1c was 7.0%. He reports occasional mild hypoglycemia.
Plan:
Continue current medication regimen. Educate patient on the signs and symptoms of hypoglycemia and how to treat it. Schedule follow-up appointment in 3 months.
Signed: Dr. Jane Smith
### EDI 278A Request Example
| Field | Value |
|-------|-------|
| Transaction Code | 278 |
| Transaction Type | Request |
| Service Type Code | HST |
| Service Type | Healthcare Services |
| Sender ID | 123456 |
| Receiver ID | 987654 |
| Patient ID | 123-45-6789 |
| Patient Name | Doe, John |
| Diagnosis Code | E11.9 |
| Diagnosis Description | Type 2 diabetes mellitus without complications |
| Service Start Date | 2023-05-01 |
| Service End Date | 2023-05-01 |
| CPT Code | 99213 |
| CPT Description | Office/outpatient visit, established patient |
| CPT Modifier | |
| CPT Quantity | 1 |
| CPT Unit Price | 100.00 |
| CPT Total Price | 100.00 |
| ICD Code | E11.9 |
| ICD Description | Type 2 diabetes mellitus without complications |
| Service Line Control Number | 1 |
## Heart Disease Clinical Document
Patient: Jane Smith
DOB: 05/01/1955
Diagnosis: Myocardial Infarction (ICD-10 I21.3)
Medications: Aspirin 81mg PO daily, Metoprolol succinate 25mg PO daily, Atorvastatin 40mg PO daily
Assessment:
Ms. Smith's cardiac function has improved since her myocardial infarction. She has had no chest pain or shortness of breath. Her most recent EKG showed no evidence of ischemia.
Plan:
Continue current medication regimen. Schedule follow-up appointment in 6 months.
Signed: Dr. John Doe
### EDI 278A Request Example
| Field | Value |
|-------|-------|
| Transaction Code | 278 |
| Transaction Type | Request |
| Service Type Code | HST |
| Service Type | Healthcare Services |
| Sender ID | 123456 |
| Receiver ID | 987654 |
| Patient ID | 987-65-4321 |
| Patient Name | Smith, Jane |
| Diagnosis Code | I21.3 |
| Diagnosis Description | ST elevation (STEMI) myocardial infarction of unspecified site |
| Service Start Date | 2023-05-01 |
| Service End Date | 2023-05-01 |
| CPT Code | 99214 |
| CPT Description | Office/outpatient visit, established patient |
| CPT Modifier | |
| CPT Quantity | 1 |
| CPT Unit Price | 150.00 |
| CPT Total Price | 150.00 |
| ICD Code | I21.3 |
| ICD Description | ST elevation (STEMI) myocardial inf
## Anxiety & Depression Clinical Document
Patient: Alice Johnson
DOB: 06/15/1980
Diagnosis: Major Depressive Disorder (ICD-10 F32.1)
Medications: Sertraline 50mg PO daily
Assessment:
Ms. Johnson reports feeling sad and unmotivated. She has trouble sleeping and has lost interest in activities she used to enjoy. She denies any suicidal ideation.
Plan:
Increase sertraline to 100mg PO daily. Schedule follow-up appointment in 2 weeks.
Signed: Dr. Sarah Lee
### EDI 278A Request Example
| Field | Value |
|-------|-------|
| Transaction Code | 278 |
| Transaction Type | Request |
| Service Type Code | HST |
| Service Type | Healthcare Services |
| Sender ID | 123456 |
| Receiver ID | 987654 |
| Patient ID | 456-78-9123 |
| Patient Name | Johnson, Alice |
| Diagnosis Code | F32.1 |
| Diagnosis Description | Major depressive disorder, single episode, moderate |
| Service Start Date | 2023-05-01 |
| Service End Date | 2023-05-01 |
| CPT Code | 90834 |
| CPT Description | Psychotherapy, 45 minutes with patient |
| CPT Modifier | |
| CPT Quantity | 1 |
| CPT Unit Price | 200.00 |
| CPT Total Price | 200.00 |
| ICD Code | F32.1 |
| ICD Description | Major depressive disorder, single episode, moderate |
| Service Line Control Number | 1 |
### Musculoskeletal Disorders Clinical Document
Patient: Mark Thompson
DOB: 02/25/1972
Diagnosis: Low Back Pain (ICD-10 M54.5)
Medications: Ibuprofen 400mg PO TID
Assessment:
Mr. Thompson reports chronic low back pain that has been getting worse over the past several months. Physical exam reveals tenderness and limited range of motion in the lumbar spine.
Plan:
Prescribe physical therapy with focus on core strengthening exercises. Schedule follow-up appointment in 4 weeks.
Signed: Dr. James Chen
| Field | Value |
|-------|-------|
| Transaction Code | 278 |
| Transaction Type | Request |
| Service Type Code | HST |
| Service Type | Healthcare Services |
| Sender ID | 123456 |
| Receiver ID | 987654 |
| Patient ID | 789-01-2345 |
| Patient Name | Thompson, Mark |
| Diagnosis Code | M54.5 |
| Diagnosis Description | Low back pain |
| Service Start Date | 2023-05-01 |
| Service End Date | 2023-05-01 |
| CPT Code | 97110 |
| CPT Description | Therapeutic exercises |
| CPT Modifier | |
| CPT Quantity | 1 |
| CPT Unit Price | 150.00 |
| CPT Total Price | 150.00 |
| ICD Code | M54.5 |
| ICD Description | Low back pain |
| Service Line Control Number | 1 |
ADT A01 Admit Transaction Example
| Field | Value |
|-------|-------|
| MSH | \|HL7\|2.6\|ADT_A01_MESSAGE\|RECEIVER_APPLICATION\|20230505120000\|SECURITY\|ADT_A01\|MSG00001\|P\|2.6\
## Big Four - Diabetes, Heart Disease, Anxiety & Depression and Muskoskeletal Disorders
| Costly Condition | Code Type | Code Value | Emoji | Code Description |
|---------------------------------|-----------|----------------------|-----------|---------------------------------------------------------|
| Diabetes | CPT | 99214, 99215 | 🩺 | Office/outpatient visit |
| | ICD-10 | E08.00 - E13.9 | 🍬 | Diabetes Mellitus |
| | SNOMED | 73211009, 44054006 | 🍬 | Diabetes Mellitus Type 1, Diabetes Mellitus Type 2 |
| | LOINC | 4548-4, 14647-2 | 🍬 | Hemoglobin A1c, Glucose |
| | Omaha | 1405-8, 1435-4 | 🍬 | Diabetes Management, Glucose Monitoring |
| Heart Disease | CPT | 92920, 92928 | 💔 | Percutaneous coronary intervention |
| | ICD-10 | I20.0 - I25.9 | 💔 | Ischemic Heart Diseases |
| | SNOMED | 53741008, 84114007 | 💔 | Coronary Artery Disease, Myocardial Infarction |
| | LOINC | 24331-1, 6768-6 | 💔 | Troponin I, Total Cholesterol |
| | Omaha | 2610-5, 2871-4 | 💔 | Hypertension Management, Lipid Management |
| Anxiety & Depression | CPT | 90791, 90834, 90837 | 😨 | Psychiatric diagnostic evaluation, psychotherapy |
| | ICD-10 | F32.0 - F39 | 😨 | Mood (Affective) Disorders |
| | SNOMED | 42343007, 39607008 | 😨 | Major Depressive Disorder, Generalized Anxiety Disorder |
| | LOINC | 75216-8, 73633-2 | 😨 | PHQ-9 Total Score, GAD-7 Total Score |
| | Omaha | 5250-7, 5361-7 | 😨 | Depression Management, Anxiety Management |
| Musculoskeletal Disorders | CPT | 97110, 97112 | 🏋️♂️ | Therapeutic exercises, neuromuscular reeducation |
| | ICD-10 | M00.00 - M99.9 | 🏋️♂️ | Diseases of the musculoskeletal system and connective tissue |
| | SNOMED | 239873007, 80931005 | 🏋️♂️ | Osteoarthritis, Low Back Pain |
| | LOINC | 8302-2, 71425-3 | 🏋️♂️ | Creatine Kinase, Aldolase |
| | Omaha | 3110-2, 3120-6 | 🏋️♂️ | Musculoskeletal Assessment, Pain Management |
| Rank | Costly Condition | Approval Code Type | Approval Codes | Code Description | Medical Necessity Rules |
|------|---------------------------------|--------------------|-------------------------|----------------------------------------|--------------------------------------------------------------------------------------------------------------------------|
| 1 | 🍬 Diabetes | CPT | 99214, 99215 | Office/outpatient visit | - Diagnosis confirmation |
| | | ICD-10 | E08.00 - E13.9 | Diabetes Mellitus | - Documented treatment plan |
| | | | | | - Medication adherence |
| | | | | | - Glucose monitoring |
| | | | | | - Physician referral |
| 2 | 💔 Heart Disease | CPT | 92920, 92928 | Percutaneous coronary intervention | - Diagnosis confirmation |
| | | ICD-10 | I20.0 - I25.9 | Ischemic Heart Diseases | - Documented treatment plan |
| | | | | | - Conservative treatment history |
| | | | | | - Cardiac risk factors |
| | | | | | - Physician referral |
| 3 | 😨 Anxiety & Depression | CPT | 90791, 90834, 90837 | Psychiatric diagnostic evaluation, psychotherapy | - Diagnosis confirmation |
| | | ICD-10 | F32.0 - F39 | Mood (Affective) Disorders | - Documented treatment plan |
| | | | | | - Severity assessment |
| | | | | | - Conservative treatment history |
| | | | | | - Physician referral |
| 4 | 🏋️♂️ Musculoskeletal Disorders | CPT | 97110, 97112 | Therapeutic exercises, neuromuscular reeducation | - Diagnosis confirmation |
| | | ICD-10 | M00.00 - M99.9 | Diseases of the musculoskeletal system and connective tissue | - Documented treatment plan |
| | | | | | - Conservative treatment history |
| | | | | | - Functional limitation |
| | | | | | - Physician referral |
| 5 | 🦷 Dental Issues | CPT | 00100, 00170 | Anesthesia for intraoral procedures, incision and drainage of abscess | - Diagnosis confirmation |
| | | ICD-10 | K00.0 - K14.9 | Diseases of oral cavity and salivary glands | - Documented treatment plan |
| | | | | | - Conservative treatment history |
| | | | | | - Dentist referral |
| 6 | 🌊 Chronic Kidney Disease | CPT | 90935, 90937 | Hemodialysis, outpatient | - Diagnosis confirmation |
| | | ICD-10 | N18.1 - N18.9 | Chronic kidney disease | - Documented treatment plan |
| | | | | | - Stage of kidney disease |
| | | | | | - Conservative treatment history |
| | | | | | - Physician referral |
## Costly Top Six with Code Description and Medical Necessity Rules
| Rank | Costly Condition | Approval Code Type | Approval Codes | Code Description | Medical Necessity Rules |
|------|---------------------------------|--------------------|-------------------------|----------------------------------------|--------------------------------------------------------------------------------------------------------------------------|
| 1 | 🍬 Diabetes | CPT | 99214, 99215 | Office/outpatient visit | Diagnosis confirmation, documented treatment plan, medication adherence, glucose monitoring, physician referral |
| | | ICD-10 | E08.00 - E13.9 | Diabetes Mellitus | |
| 2 | 💔 Heart Disease | CPT | 92920, 92928 | Percutaneous coronary intervention | Diagnosis confirmation, documented treatment plan, conservative treatment history, cardiac risk factors, physician referral |
| | | ICD-10 | I20.0 - I25.9 | Ischemic Heart Diseases | |
| 3 | 😨 Anxiety & Depression | CPT | 90791, 90834, 90837 | Psychiatric diagnostic evaluation, psychotherapy | Diagnosis confirmation, documented treatment plan, severity assessment, conservative treatment history, physician referral |
| | | ICD-10 | F32.0 - F39 | Mood (Affective) Disorders | |
| 4 | 🏋️♂️ Musculoskeletal Disorders | CPT | 97110, 97112 | Therapeutic exercises, neuromuscular reeducation | Diagnosis confirmation, documented treatment plan, conservative treatment history, functional limitation, physician referral |
| | | ICD-10 | M00.00 - M99.9 | Diseases of the musculoskeletal system and connective tissue | |
| 5 | 🦷 Dental Issues | CPT | 00100, 00170 | Anesthesia for intraoral procedures, incision and drainage of abscess | Diagnosis confirmation, documented treatment plan, conservative treatment history, dentist referral |
| | | ICD-10 | K00.0 - K14.9 | Diseases of oral cavity and salivary glands | |
| 6 | 🌊 Chronic Kidney Disease | CPT | 90935, 90937 | Hemodialysis, outpatient | Diagnosis confirmation, documented treatment plan, stage of kidney disease, conservative treatment history, physician referral |
| | | ICD-10 | N18.1 - N18.9 | Chronic kidney disease | |
## Costly Top Six:
| Rank | Costly Condition | 💰 Spending (billions) | CPT Range Start | CPT Range Finish | ICD-10 Diagnosis Codes |
|------|---------------------------------|------------------------|-----------------|------------------|------------------------|
| 1 | 🍬 Diabetes | 327 | 48100 | 48999 | E08.00 - E13.9 |
| 2 | 💔 Heart Disease | 230 | 92920 | 93799 | I20.0 - I25.9 |
| 3 | 😨 Anxiety & Depression | 210 | 90791 | 90899 | F32.0 - F39 |
| 4 | 🏋️♂️ Musculoskeletal Disorders | 176 | 97110 | 97799 | M00.00 - M99.9 |
| 5 | 🦷 Dental Issues | 130 | 00100 | 00192 | K00.0 - K14.9 |
| 6 | 🌊 Chronic Kidney Disease | 110 | 50010 | 50999 | N18.1 - N18.9 |
## Service Types and Associated Evidence of Med Nec
| No. | Service Type | CPT Code Range | Rules for Required Evidence of Medical Necessity |
|-----|-----------------------------|----------------------|--------------------------------------------------------|
| 1 | 🫀 Organ Transplant | 50300-50380 | Diagnosis📄, waiting list📃, physician referral👩⚕️ |
| 2 | 🦴 Spinal Fusion Surgery | 22532-22812 | Diagnosis📄, conservative treatment history📚, physician referral👩⚕️ |
| 3 | 🍔 Bariatric Surgery | 43644-43775 | BMI🏋️, documented weight loss attempts📉, physician referral👩⚕️, psychological evaluation🧠 |
| 4 | 🦵 Joint Replacement Surgery | 27130-27447 | Diagnosis📄, conservative treatment history📚, physician referral👩⚕️ |
| 5 | 💉 Chemotherapy | 96401-96549 | Cancer diagnosis🦠, treatment plan💊, medication💊, dosage💊, frequency💊 |
| 6 | ☢️ Radiation Therapy | 77261-77799 | Cancer diagnosis🦠, treatment plan💊, physician referral👩⚕️ |
| 7 | ❤️ Cardiac Surgery | 33010-33999 | Diagnosis📄, conservative treatment history📚, physician referral👩⚕️ |
| 8 | 🧊 Dialysis | 90935-90999 | Diagnosis of kidney disease🩸, treatment plan💊, physician referral👩⚕️ |
| 9 | 🫁 Gastrointestinal Surgery | 43620-44979 | Diagnosis📄, conservative treatment history📚, physician referral👩⚕️ |
| 10 | 🖼️ Advanced Imaging Services | 70450-72159 (CT), 70540-72198 (MRI) | Clinical history📚, prior relevant imaging📸, symptoms justification😷 |
| 11 | 🎯 Interventional Radiology | 37220-37235 | Diagnosis📄, conservative treatment history📚, physician referral👩⚕️ |
| 12 | 🛌 Sleep Study | 95800-95811 | Documented sleep disorder symptoms😴, sleep diary📘, physician referral👩⚕️ |
| 13 | 💉 Infusion Therapy | 96360-96549 | Diagnosis📄, medication💊, dosage💊, frequency💊, duration⏳ |
| 14 | 💊 Pain Management | 64400-64530 | Diagnosis📄, conservative treatment history📚, treatment plan💊 |
| 15 | ❤️ Cardiac Stress Test | 93015-93018 | Documented symptoms😷, cardiac risk factors❤️, physician referral👩⚕️ |
| 16 | 🫁 Pulmonary Function Test | 94010-94799 | Documented respiratory issues😷, physician referral👩⚕️ |
| 17 | 🏃♂️ Physical Therapy | 97110-97546 | Diagnosis📄, treatment plan💊, physician referral👩⚕️ |
| 18 | 🧠 Mental Health Services | 90791-90899 | Diagnosis📄, treatment plan💊, physician referral👩⚕️ |
| 19 | 👓 Vision Services | 92002-92499 | Diagnosis📄, conservative treatment history📚, physician referral👩⚕️ |
| 20 | 👂 Hearing Services | 92502-92700 | Diagnosis📄, conservative treatment history📚, physician referral👩⚕️ |
## Services Descending by Costly with CPT and ICD10 code ranges
| Rank | Costly Condition | 💰 Spending (billions) | CPT Range Start | CPT Range Finish | ICD-10 Diagnosis Codes |
|------|-----------------------------|------------------------|-----------------|------------------|------------------------|
| 1 | 🍬 Diabetes | 327 | 48100 | 48999 | E08.00 - E13.9 |
| 2 | 💔 Heart Disease | 230 | 92920 | 93799 | I20.0 - I25.9 |
| 3 | 😨 Anxiety & Depression | 210 | 90791 | 90899 | F32.0 - F39 |
| 4 | 🏋️♂️ Musculoskeletal Disorders | 176 | 97110 | 97799 | M00.00 - M99.9 |
| 5 | 🦷 Dental Issues | 130 | 00100 | 00192 | K00.0 - K14.9 |
| 6 | 🌊 Chronic Kidney Disease | 110 | 50010 | 50999 | N18.1 - N18.9 |
| 7 | 😷 Chronic Obstructive Pulmonary Disease | 70 | 94002 | 94799 | J44.0 - J44.9 |
| 8 | 🍺 Liver Disease | 40 | 47000 | 47999 | K70.0 - K77.9 |
| 9 | 🤧 Allergies | 25 | 31231 | 31294 | J30.0 - J39.9 |
| 10 | 🔥 Gastroesophageal Reflux Disease | 17 | 43200 | 43289 | K21.0 - K21.9 |
| 11 | 🎗️ Endometriosis | 22 | 56405 | 58999 | N80.0 - N80.9 |
| 12 | 🚽 Inflammatory Bowel Disease | 14.6 | 44140 | 44238 | K50.00 - K52.9 |
| 13 | 📢 Hearing Loss | 7.1 | 92502 | 92700 | H90.0 - H94.9 |
| 14 | 👓 Cataracts | 10.7 | 92002 | 92499 | H25.0 - H28.9 |
| 15 | 🦠 Hypothyroidism | 3.1 | 60210 | 60271 | E00.0 - E03.9 |
| 16 | 🩸 Anemia | 5.6 | 38100 | 38199 | D50.0 - D64.9 |
| 17 | 😰 Adrenal Disorders | 1 | 60500 | 60699 | E27.0 - E27.9 |
| 18 | 🌞 Skin Cancer | 8.1 | 96910 | 96999 | C43.0 - C44.9 |
| 19 | 💧 Urinary Incontinence | 8 | 51700 | 51798 | N39.3 - N39.4 |
| 20 | 🤕 Peripheral Neuropathy | 19 | 95900 | 96004 | G60.0 - G65.9 |
| 21 | 🍼 Asthma | 6 | 94010 | 94799 | J45.0 - J45.9 |
| 22 | 🦠 Infections | 15 | 10060 | 17999 | A00.0 - B99.9 |
| 23 | 🧠 Neurological Disorders | 12 | 95805 | 95872 | G00.0 - G99.9 |
| 24 | 🤰 Pregnancy Complications | 20 | 59000 | 59899 | O00.0 - O9A.9 |
| 25 | 💉 Blood Disorders | 8 | 38200 | 38999 | D65.0 - D89.9 |
| 26 | 🏥 Hospital-Acquired Conditions | 7 | 99800 | 99899 | E87.0 - E87.9 |
| 27 | 🦴 Osteoporosis | 5 | 73300 | 73399 | M80.0 - M82.9 |
| 28 | 🤒 Infectious Diseases | 10 | 00300 | 00352 | A00.0 - A99.9 |
| 29 | 🤕 Traumatic Injuries | 9 | 11000 | 11012 | S00.0 - T98.9 |
| 30 | 🍔 Obesity | 4 | 27800 | 27899 | E66.0 - E66.9 |
## 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 | |
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