Healthcare Revenue Cycle

Pre-Certification Assignment:

1.Review the
criteria and indicators for pre-certification for a pediatric tonsillectomy
outpatient surgery procedure.

2.Review the
medical records provided.

3.Compare clinical
documentation to determine if the pre-certification criteria were met or
not.

Pre-certification
Assignment Instructions

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.