Utilization Review- Suggested Examiner/ URO Triggers

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Transcription:

Utilization Review- Suggested Examiner/ URO Triggers UR Request EXAINER UR ACOE/TUS =ANDATORY ACOE TUS BODY PART/ EXAPLE Evaluation and anagement Non-emergency inpatient Hospital admissions () Evaluations of outpatient surgical and ambulatory surgical services (D) D X X All pre-approved NA Surgery Nursing home, convalescent, residential treatment () All non-emergent surgical procedures, unless recommended by AE/QE () UR Codes - 1

EXAINER UR ACOE/TUS =ANDATORY ACOE TUS BODY PART/ EXAPLE External and implantable bone growth stimulators () Injections: Botulinum Toxin (Bo-Tox); Epidural Spinal Injections (ESI); Trigger point injections () orphine pump implant () Emergency surgery (D) D NA NA All pre-approved NA All pre-operative tests related to approved surgery (D) D X X All pre-approved NA UR Codes - 2

EXAINER UR ACOE/TUS =ANDATORY ACOE TUS BODY PART/ EXAPLE Radiology yelograms, Discograms, Surface EG s () Repeat diagnostics ()*** Electromyelogram/ nerve conduction studies () Bone scans () Imaging (RI, CT Scans): Prior to 4 week course of conservative treatment () Imaging (RI, CT Scans): After 4 week course of conservative treatment (D) D X X VARIOUS NA UR Codes - 3

EXAINER UR ACOE/TUS =ANDATORY ACOE TUS BODY PART/ EXAPLE edicine Chemical dependency and weight loss programs () Chronic pain management/ interdisciplinary pain rehab programs - Inpatient/Outpatient () Initial Psychological testing and psychotherapy ()*** Aquatic therapy () Gym memberships () Speech therapy () UR Codes - 4

EXAINER UR ACOE/TUS =ANDATORY ACOE TUS BODY PART/ EXAPLE Work Hardening and Work Conditioning Programs () Repeat psychological interviews and biofeedback (D)*** D X Stress Relaxation Techniques Biofeedback Initial treatment requests for Physical/Occupational Therapy and Chiropractic Treatment/Acupuncture ALL BODY PARTS NOT TO EXCEED 12 VISITS (D) D X Shoulder Disorders PT/Chiro Strengthening/stabilization acute/subacute; may include massage or ultrasound when part of home exercise program Impingement Rotator cuff tear Shoulder instability Dislocation anipulation (acute) Adhesive capsulitis X Neck/Upper Back GENERAL: Stretching Specific neck exercises for range of motion and strengthening UR Codes - 5

EXAINER UR ACOE/TUS =ANDATORY ACOE TUS BODY PART/ EXAPLE Relaxation techniques Aerobic exercise 1-2 physical therapy visits for education, counseling, and evaluation of home exercise X Low Back Disorders Low Back Pain CHIRO or PT (acute/sub-acute/chronic) anipulation/mobilization (acute/sub acute only) assage (acute) Chronic Low Back Pain Acupuncture X Knee Disorders GENERAL: Stretching Specific knee exercises for range of motion and strengthening X Ankle/Foot Disorders GENERAL: Stretching Specific foot and ankle exercises for range of motion and strengthening Aerobic exercise UR Codes - 6

EXAINER UR ACOE/TUS =ANDATORY ACOE TUS BODY PART/ EXAPLE X Forearm/Wrist/ Hand GENERAL: Disorders Stretching Specific hand and wrist exercises for range of motion and strengthening Aerobic exercise to maintain general conditioning Initial and follow-up visits for education, counseling, and evaluating home exercise Possible Ultrasound X Elbow Disorders Lateral/edial Epicondylitis Specific elbow exercises for range of motion and, if needed, strengthening Aerobic exercise to maintain general conditioning Ultrasound Iontophoresis Acupuncture Possible massage Biceps Tendinosis UR Codes - 7

EXAINER UR ACOE/TUS =ANDATORY ACOE TUS BODY PART/ EXAPLE Range of motion exercises transitioning to strengthening Home health care services () Consultation or Specialist Request (D) D X X Pre-approved NA DE/ Pharmacy Transcutaneous/Percutaneous electrical stimulation (TENS, PENS), Interferential Unit (INF) () Durable edical Equipment (DE) that does not exceed $350 (e.g. inserts, braces, orthotics, cold therapy units)(d) D Pre-approved UR Codes - 8

EXAINER UR ACOE/TUS =ANDATORY Initial edication order (consult if narcotic use) (D) ACOE TUS BODY PART/ EXAPLE Sprains/strains musculoskeletal D X Pre-approved aches/pain NSAIDS Investigate, experimental services Repeat edication order (consult if narcotic use) (D) Intradiscal Electrotherapy (IDET) () D X Pre-approved Sprains/strains musculoskeletal aches/pain NSAIDS Vax-D () Non FDA approved procedures () Electroconvulsive therapy (ECT)(Psyche) () UR Codes - 9

EXAINER UR ACOE/TUS =ANDATORY ACOE TUS BODY PART/ EXAPLE Shock wave therapy (Orthopedic) () ***Requests relating to QE or AE examination are not covered by UR. UR Codes - 10

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