Admin: Medical Necessity

Page Description

Use the Medical Necessity page to create the validation sets Copia uses when performing medical necessity checking during order entry. A validation set contains one or more CPT codes that are in turn mapped to one or more ICD codes. In addition, you may set a limit on how often testing may be performed for specific ICD codes within the validation set. When Copia performs medical necessity checking, it determines whether or not the patient's insurance considers the testing medically necessary (and therefore a covered expense), based on whether the diagnosis codes assigned to the order are included in the validation set the insurance company uses and on the frequency setting for the ICD code.

Use the Medical Necessity tab to establish validation sets by adding CPT codes and mapping ICD codes to the CPT codes. Use the CPT, ICD-9, and ICD-10 tabs to manually add or edit CPT and ICD-9/ICD-10 codes that you may then use in validation sets. You may import ICD and CPT codes in bulk using the Import Configuration administration page. See the Admin: Import Configuration topic. However, if you need to add or edit only a few codes, you may wish to manually add or edit them in this page.

For more help, click one of the following links:

Medical Necessity Tab

CPT Tab

ICD-9 Tab

ICD-10 Tab

Accessing this Page

[Return to Top]

Creating Validation Sets
  1. Before you may associate CPT codes with ICD-9 codes, you must select the validation set to which the CPT/ICD-9 relationship belongs from the Validation Set field on the Medical Necessity tab.
  2. If you cannot find the desired validation set, click the Add Validation Set button to enter the validation set name in the prompt field. See "Adding, Renaming, or Deleting Validation Sets" below.
  3. Once you have selected a validation set, select an existing CPT code using the search field, or add a new CPT code to the validation set. See "Viewing CPT Codes in a Validation Set" below.
  4. Once you have found or entered a CPT code, click the CPT link to display the mapped ICD-9 codes for that CPT code.
  5. If there are no mapped codes, or if you wish to map a new ICD-9 code, click the Add ICD-9 for CPT button to enter the new code. See "Viewing ICD-9 Code Mappings in a Validation Set" below.
  6. Once you find the ICD-9 code, Copia returns you to this page, with the newly mapped ICD-9 code added to the list. This ICD-9 code is now valid for the selected validation set when Copia performs medical necessity checking.
  7. Continue adding CPT codes and their associated ICD-9 codes, as desired.
  8. If you need to add additional CPT or ICD-9 codes, use the CPT or ICD-9 tabs. See "Viewing and Adding System CPT Codes" or "Viewing and Adding System ICD-9 Codes" below.

[Return to Top]

Adding, Renaming, or Deleting Validation Sets
  1. To add a validation set, click the Add button to enter the validation set name in the prompt field. Click OK to return to the Medical Necessity page with the new set selected in the Validation Set drop-down list.
  2. To rename a validation set, select the set in the Validation Set field, and then click the Rename button. Enter the new name for the set, and then click OK to update the name.
  3. To delete a validation set, select the set in the Validation Set field, and then click the Delete button. Copia prompts you to confirm the deletion. Click OK to continue.

    4. IMPORTANT: When you delete a validation set, Copia removes all references to the validation set throughout the database.

[Return to Top]

Viewing CPT Codes in a Validation Set
  1. Before you may associate CPT codes with the validation set, you must select a validation set. See "Creating Validation Sets" above.
  2. After you have selected a validation set, Copia displays the CPT codes that have been added to the set, if any, in the CPT Codes in Selected Set section.
  3. To narrow the list of displayed CPT codes, or to find a specific code within the list of codes within the validation set, use the Search option. Click the List option to return to the full list of CPT codes within the validation set. See "Searching for a CPT Code" below.
  4. If you cannot find the desired CPT code or if you wish to add a new CPT code to the validation set, click the Add CPT to Set button. See "Adding or Removing CPT Codes in the Validation Set" below.
  5. After adding a new CPT code or searching for a code, click the List option to view the full list of CPT codes within the validation set.
  6. Click the CPT link in the CPT Codes in Selected Set section to display the ICD-9 codes linked to the CPT code in the Mapped ICD-9 Codes for CPT ____ section. Note that when you add a new CPT code to the validation set, Copia automatically displays any ICD-9 codes linked to the CPT code in the Mapped ICD-9 Codes for CPT ____ section.
  7. Once you select a specific CPT code, either by adding a new code or by clicking a code in the list, you may add valid ICD-9 codes. See "Adding or Deleting ICD-9 Code Mappings in a Validation Set" below.

[Return to Top]

Searching for a CPT Code
  1. Select the Search option in the CPT Codes in Selected Set section to search the list of CPT codes within the validation set.
  2. Enter one or more characters of the code or description in the Search field, and then click the Search button.
  3. If your search generates one or more matches, Copia displays the matching codes and descriptions.

    4. Note that if you search on part of a CPT code, Copia will only display those codes that begin with the characters you type. For example, if you type "11," Copia only displays the codes that begin with "11" (e.g., 11001, 11052, 11987, etc.); it does not display codes that contain "11" (e.g., 34119, 21101, 65411, etc.).

  4. If no search results are found or if the desired code is not found, search again, or click the Add CPT to Set button to add a CPT code to the validation set. See "Adding or Removing CPT Codes in a Validation Set" below.
  5. Click the List option to view the full list of CPT codes within the validation set. See "Viewing CPT Codes in a Validation Set" above.

[Return to Top]

Adding or Removing CPT Codes in the Validation Set

In order for Copia to run diagnosis codes against all of the CPT codes on an order choice, not just the first one, be sure the "Require exact mappings for all code pairs to determine valid ICD-9 codes" setting on the System Defaults administration page is enabled.

  1. Copia displays the CPT codes that have been added to the set, if any, in the CPT Codes in Selected Set section.
  2. When viewing CPT codes, if you cannot find the desired CPT code or if you wish to add a new CPT code to the validation set, click the Add CPT to Set button to select the new CPT code for the validation set in the CPT Search page. See the Admin: CPT Search topic. Once you select the CPT code, Copia returns you to the Medical Necessity page.
  3. After you add a new CPT code, Copia lists the code in the CPT Codes in Selected Set section and lists any ICD-9 codes linked to the CPT code in the Mapped ICD-9 Codes for CPT ____ section.
  4. You may proceed to map ICD-9 codes to the CPT code. See "Adding or Deleting ICD-9 Code Mappings to CPT Codes in a Validation Set" below.
  5. To remove a CPT code from the validation set, click the X button in the Remove column that corresponds to the code you wish to remove. This completely removes the selected CPT code from the validation set and erases all of the ICD-9 mappings for the CPT code. Copia prompts you to confirm the deletion. Click OK to continue.

[Return to Top]

Viewing ICD Code Mappings in a Validation Set
  1. Before you may map ICD-9 codes to CPT codes within a validation set, you must select a validation set and a CPT code. See "Creating Validation Sets" or "Viewing CPT Codes in a Validation Set" above.
  2. Once you select your validation set and CPT code, Copia displays any ICD-9 codes already mapped to the selected CPT Code in the Mapped ICD-9 Codes for CPT ___ section. Note that Copia displays the name of the currently selected CPT code in the section title bar (e.g., "Mapped ICD-9 Codes for CPT 11052").
  3. To narrow the list of displayed mapped ICD-9 codes, or to find a specific code within the list of mapped codes, use the Search option. Click the List option to return to the full list of mapped ICD-9 codes. See "Searching for an ICD-9 Code" below.
  4. If you cannot find the desired ICD-9 code or if you wish to map a new ICD-9 code to the CPT code, click the Add ICD-9 for CPT button. See "Adding or Deleting ICD-9 Code Mappings to CPT Codes in a Validation Set" below.
  5. After adding a new ICD-9 code or searching for a code, click the List option to view the full list of ICD-9 codes mapped to the selected CPT code.
  6. Click the Frequency link in the Mapped ICD-9 Codes for CPT ___ section to view the ICD-9 details or modify the frequency limit in the Mapped ICD-9 Details administration page. See the Admin: Mapped ICD-9 Details topic.

[Return to Top]

Adding or Deleting ICD Code Mappings to CPT Codes in the Validation Set
  1. Copia displays any ICD-9 codes already mapped to the selected CPT Code in the Mapped ICD-9 Codes for CPT ___ section. Note that Copia displays the name of the currently selected CPT code in the section title bar (e.g., "Mapped ICD-9 Codes for CPT 11052").
  2. When viewing mapped ICD-9 codes, if you cannot find the desired ICD-9 code or if you wish to map a new ICD-9 code to the CPT code, click the Add ICD-9 for CPT button to select the new ICD-9 code to map in the ICD-9 Search page. See the Admin: ICD-9 Search topic. Once you select the ICD-9 code, Copia returns you to the Medical Necessity page.
  3. After you map a new CPT code, Copia lists the ICD-9 code in the Mapped ICD-9 Codes for CPT ____ section. This ICD-9 code is now valid when Copia performs medical necessity checking using the selected validation set.
  4. To delete the mapping of the ICD-9 code to the currently selected CPT code, click the X button in the Delete column that corresponds to the mapped code you wish to delete. This clears the association between the ICD-9 code and the selected CPT code; however, this does not delete the ICD-9 code from the system. This means that the ICD-9 code will still be associated with any other CPT codes it is mapped to, and you may still map the ICD-9 code to other CPT codes.

[Return to Top]

Searching for ICD Codes
  1. Select the Search option in the Mapped ICD-9 Codes for CPT ___ section to search the list of mapped ICD-9 codes.
  2. Enter one or more characters of the code or description in the Search field, and then click the Search button.
  3. If your search generates one or more matches, Copia displays the matching codes, with their frequency settings and descriptions.

    4. Note that if you search on part of an ICD-9 code, Copia will only display those codes that begin with the characters you type. For example, if you type "00," Copia only displays the codes that begin with "00" (e.g., 001.9, 003.0, etc.); it does not display codes that contain "00" (e.g., 100.81, 500, etc.). It will, however, display ICD-9 codes that contain "00" within the description (e.g., "LOW BIRTHWT 2000-2500G").

  4. If no search results are found or if the desired code is not found, search again, or click the Add ICD-9 for CPT button to map a new ICD-9 code. See "Adding or Deleting ICD-9 Code Mappings to CPT Codes in a Validation Set" above.
  5. Click the List option to view the full list of mapped ICD-9 codes. See "Viewing ICD-9 Code Mappings in a Validation Set" above.

[Return to Top]

Viewing and Adding System CPT Codes

You may import CPT codes in bulk using the Import Configuration page. However, if you need to add or edit only a few codes, you may wish to manually add them on the CPT tab of the Medical Necessity page.

  1. Click the CPT tab to open the list of the CPT codes in the system.
  2. The page contains a list of up to ten CPT codes and their descriptions. If the list is longer than one page, use the Page links, located below the list of CPT codes, to navigate through the list.
  3. To view active CPT codes only, select the Show active only checkbox at the top of the CPT List view of the CPT tab. You set the active/inactive status in the CPT Details view of the CPT tab. See "Editing System CPT Codes" below.
  4. Click the Code link to view the CPT Code and Description in the CPT Details view of the CPT tab. From here, you may edit the description or active status of the code. See "Editing System CPT Codes" below.
  5. Before adding a CPT code, use the Search option to search the CPT codes in the system to verify the code does not already exist. Click the List option to return to the full list of CPT codes within the system. The Search and List options work as they do when you are adding CPT codes to validation sets. See "Searching for a CPT Code" above.
  6. To add a new CPT code, click the Add button to open the CPT Details view of the CPT tab.
  7. Enter the CPT Code in the CPT Code field, and then click the Load button. This field is required.
  8. Click Cancel to return to the CPT List view of the CPT tab without adding a CPT code.
  9. Click Save to record changes and return to the CPT List view of the CPT tab with the CPT code added to the system. You may then add the CPT code to validation sets. See "Creating Validation Sets" above.

[Return to Top]

Editing System CPT Codes

  1. If you are editing the CPT code you selected in the CPT List view of the CPT tab, or if you tried to add a CPT code that already exists (see "Viewing and Adding System CPT Codes" above), you may only edit the description and active status of the code. You cannot modify the CPT code itself once you have entered it into the system.
  2. To edit the CPT code description, highlight or delete text already displayed in the Description field, then modify as desired.
  3. To change the active status, select or clear the Active checkbox. Select this checkbox to enable users to select this CPT code for validation sets. Clear this checkbox to restrict users from selecting the CPT code and to remove this CPT code from any validation sets it currently belongs to. If the CPT code is inactive, Copia clears it from the CPT List view of the CPT tab when you select the Show active only checkbox. See "Viewing and Adding System CPT Codes" above.
  4. Click < Back to List to return to the CPT List view of the CPT tab without adding a CPT code.
  5. Click Save to record changes and return to the CPT List view of the CPT tab.

[Return to Top]

Viewing and Adding System ICD-9 Codes

You may import ICD-9 codes in bulk using the Import Configuration page. However, if you need to add or edit only a few codes, you may wish to manually add them on the ICD-9 tab of the Medical Necessity page.

  1. Click the ICD-9 tab to open the list of the ICD-9 codes in the system.
  2. The page contains a list of up to ten ICD-9 codes and their descriptions. If the list is longer than one page, use the Page links, located below the list of ICD-9 codes, to navigate through the list.
  3. To view active ICD-9 codes only, select the Show active only checkbox at the top of the ICD-9 List view of the ICD-9 tab. You set the active/inactive status in the ICD-9 Details view of the ICD-9 tab. See "Editing System ICD-9 Codes" below.
  4. Click the Code link to view the ICD-9 Code and Description in the ICD-9 Details view of the ICD-9 tab. From here, you may edit the description or active status of the code. See "Editing System ICD-9 Codes" below.
  5. Before adding an ICD-9 code, use the Search option to search the ICD-9 codes in the system to verify the code does not already exist. Click the List option to return to the full list of ICD-9 codes within the system. The Search and List options work as they do when you are mapping ICD-9 codes to CPT codes in a validation set. See "Searching for an ICD-9 Code" above.
  6. To add a new ICD-9 code, click the Add button to open the ICD-9 Details view of the ICD-9 tab.
  7. Enter the ICD-9 code in the ICD-9 Code field, and then click the Load button. This field is required. Note that you may enter only up to six characters for the ICD-9 code.
  8. Click Cancel to return to the ICD-9 List view of the ICD-9 tab without adding an ICD-9 code.
  9. Click Save to record changes and return to the ICD-9 List view of the ICD-9 tab with the ICD-9 code added to the system. You may then add the ICD-9 code to validation sets. See "Creating Validation Sets" above.

[Return to Top]

Editing System ICD-9 Codes

  1. If you are editing the ICD-9 code you selected in the ICD-9 List view of the ICD-9 tab, or if you tried to add an ICD-9 code that already exists (see "Viewing and Adding System ICD-9 Codes" above), you may only edit the description and active status of the code. You cannot modify the ICD-9 code itself once you have entered it into the system.
  2. To edit the ICD-9 code description, highlight or delete text already displayed in the Description field, then modify as desired.
  3. To change the active status, select or clear the Active checkbox. Select this checkbox to enable users to map this ICD-9 code to CPT codes for validation sets. Clear this checkbox to restrict users from mapping the ICD-9 code and to remove this ICD-9 code from any validation sets it currently belongs to. If the ICD-9 code is inactive, Copia clears it from the ICD-9 List view of the ICD-9 tab when you select the Show active only checkbox. See "Viewing and Adding System ICD-9 Codes" above.
  4. Click < Back to List to return to the ICD-9 List view of the ICD-9 tab without adding an ICD-9 code.
  5. Click Save to record changes and return to the ICD-9 List view of the ICD-9 tab.

[Return to Top]

Viewing and Adding System ICD-10 Codes

You may import ICD-10 codes in bulk using the Import Configuration page. However, if you need to add or edit only a few codes, you may wish to manually add them on the ICD-10 tab of the Medical Necessity page.

  1. Click the ICD-10 tab to open the list of the ICD-10 codes in the system.
  2. The page contains a list of up to ten ICD-10 codes and their descriptions. If the list is longer than one page, use the Page links, located below the list of ICD-10 codes, to navigate through the list.
  3. To view active ICD-10 codes only, select the Show active only checkbox at the top of the ICD-10 List view of the ICD-10 tab. You set the active/inactive status in the ICD-10 Details view of the ICD-10 tab. See "Editing System ICD-10 Codes" below.
  4. Click the Code link to view the ICD-10 Code and Description in the ICD-10 Details view of the ICD-10 tab. From here, you may edit the description or active status of the code. See "Editing System ICD-10 Codes" below.
  5. Before adding an ICD-10 code, use the Search option to search the ICD-10 codes in the system to verify the code does not already exist. Click the List option to return to the full list of ICD-10 codes within the system. The Search and List options work as they do when you are mapping ICD-10 codes to CPT codes in a validation set. See "Searching for an ICD-10 Code" above.
  6. To add a new ICD-10 code, click the Add button to open the ICD-10 Details view of the ICD-10 tab.
  7. Enter the ICD-10 code in the ICD-10 Code field, and then click the Load button. This field is required. Note that you may enter only up to six characters for the ICD-10 code.
  8. Click Cancel to return to the ICD-10 List view of the ICD-10 tab without adding an ICD-10 code.
  9. Click Save to record changes and return to the ICD-10 List view of the ICD-10 tab with the ICD-10 code added to the system. You may then add the ICD-10 code to validation sets. See "Creating Validation Sets" above.

[Return to Top]

Editing System ICD-10 Codes

  1. If you are editing the ICD-10 code you selected in the ICD-10 List view of the ICD-10 tab, or if you tried to add an ICD-10 code that already exists (see "Viewing and Adding System ICD-10 Codes" above), you may only edit the description and active status of the code. You cannot modify the ICD-10 code itself once you have entered it into the system.
  2. To edit the ICD-10 code description, highlight or delete text already displayed in the Description field, then modify as desired.
  3. To change the active status, select or clear the Active checkbox. Select this checkbox to enable users to map this ICD-10 code to CPT codes for validation sets. Clear this checkbox to restrict users from mapping the ICD-10 code and to remove this ICD-10 code from any validation sets it currently belongs to. If the ICD-10 code is inactive, Copia clears it from the ICD-10 List view of the ICD-10 tab when you select the Show active only checkbox. See "Viewing and Adding System ICD-10 Codes" above.
  4. Click < Back to List to return to the ICD-10 List view of the ICD-10 tab without adding an ICD-10 code.
  5. Click Save to record changes and return to the ICD-10 List view of the ICD-10 tab.

[Return to Top]

 © 2016 Orchard Software Corporation