Review the criteria and indicators for pre-certification for a pediatric tonsillectomy outpatient surgery procedure.
Review the medical records provided. (These pages are best viewed in print.)
Compare clinical documentation to determine if the pre-certification criteria were met or not.
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 the insurance company with information about the patient’s condition and treatment plan. 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 are 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-certification criteria and patient histories (shown in the figures that follow), compare the three patients’ histories to the criteria for tonsillectomy/adenoidectomy. Determine whether the patient should be approved for the procedure or not. Submit to your instructor for grading a summary page that includes the patient number and which criteria you used for each patient (for example, 200 Chronic Tonsillitis), and then identify the specific criteria that the patient met (for example, 211 Throat pain and 212-4 documented increase in tonsil size) or explain why the patient did not meet the criteria for the procedure.
Submit your answers for the three patients. (You might need to use the zoom feature in Word to see the information clearly)
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