Most healthcare insurance plans require that every planned hospital admission or outpatient procedure be pre-certified. This means that the physician’s office on behalf of the patient has contacted them with information about the patient’s condition and their plans for treatment. The purpose for this contact is so that the insurance company authorizes the treatment for payment.
In this assignment, you will be conducting this pre-certification authorization for three patients that need a tonsillectomy/adenoidectomy procedure performed. You will need to open the PDF file in this module to complete this assignment. In this PDF file you will find the pre-certification criteria and the history and physical for the three patients. The criteria is triggered by the patient’s diagnosis. For example, if a patient has been diagnosed with Obstructive tonsillar hypertrophy, then criteria 400 will apply. In criteria 400, all three indicators (410 Symptoms (Sx)/findings; 420 3+/4 tonsillar enlargement by physical exam (PE); and 430 Normal palate by PE) must be met for approval. Under the indicator 410 Sx/findings – one item in 411-415 must be present, and if the indicator is 415 – one item list under 415, -1 Weight loss, -2 Failure to thrive, or -3 Dysphagia with solids must be present.
Using the Pre-cert criteria and patient histories, compare the three patient’s histories to the criteria for tonsillectomy/adenoidectomy. Determine if the patient should be approved for the procedure or not. Submit a summary page to your instructor for grading that includes: the patient number, which criteria you used for each patient (eg. 200 Chronic Tonsillitis) and then identify the specific criteria that the patient met (eg. 211 Throat pain and 212-4 Documented increase in tonsil size) or explain why the patient did not meet the criteria for the procedure.
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Introduction: In this assignment, we will be conducting pre-certification authorization for three patients that need a tonsillectomy/adenoidectomy procedure performed. Using the pre-cert criteria and patient histories, we will compare the three patient’s histories to the criteria for tonsillectomy/adenoidectomy and determine if the patient should be approved for the procedure or not.
1. What is pre-certification and why is it required for hospital admissions or outpatient procedures?
Pre-certification is a process where the physician’s office on behalf of the patient contacts the healthcare insurance plans with information about the patient’s condition and their plans for treatment. The purpose of this contact is to authorize the treatment for payment by the insurance company. Pre-certification is required for hospital admissions or outpatient procedures to ensure that the treatment provided is medically necessary and meets the criteria of the insurance company.
2. What are the pre-certification criteria for tonsillectomy/adenoidectomy procedure?
The pre-certification criteria for tonsillectomy/adenoidectomy procedure depend on the patient’s diagnosis, which triggers specific criteria. For example, if a patient has been diagnosed with obstructive tonsillar hypertrophy, then criteria 400 will apply. Criteria 400 requires all three indicators (410 Symptoms/findings; 420 3+/4 tonsillar enlargement by physical exam (PE); and 430 Normal palate by PE) to be met for approval. Under indicator 410 Symptoms/findings – one item in 411-415 must be present, and if the indicator is 415 – one item list under 415, -1 Weight loss, -2 Failure to thrive, or -3 Dysphagia with solids must be present.
3. How do we determine if the patient should be approved for the tonsillectomy/adenoidectomy procedure?
To determine if the patient should be approved for the tonsillectomy/adenoidectomy procedure, we need to compare the patient’s history to the pre-certification criteria for the procedure. We need to evaluate which criteria applies to the patient’s diagnosis and determine if the patient meets all the criteria under that indicator or not. If the patient meets all the criteria under the indicator, they should be approved for the procedure. If the patient does not meet the criteria under the indicator, they should not be approved for the procedure.
