Utilization Management

Summary

This enhancement to Utilization Management (UM) updates how the UM workflow handles procedure codes that are modified after UM was completed. Procedure codes that were replaced will not require UM to be re-done for the new replacement procedure, while procedure codes that were added (and meet the rules to require UM) will be treated as a new procedure with a UM Clock that starts at 0.

Feature Description

It is common at RadNet for a procedure code that has been through UM Review to be replaced with a different Procedure Code at some later point in the workflow. For example, an MR Brain W might have completed UM Review, but at the time of registration, it is changed to an MR Brain W WO (or sometimes even a more significant change like a CT Head W).

Previously, the UM workflow considered this change to be a new procedure that must go through UM Review again with a Created Date matching the originally ordered procedure (and thus a UM Clock that was already well underway). Additionally, these orders would not fall back to the UM Review WL, so the UM team was unaware there was a new review to be done, impacting turnaround times.

With this change:

·         If a procedure code is replaced (i.e., the procedure is removed via the “black x” and replaced with a different procedure or the procedure is changed from the Documentation tab on View/Edit or Perform Exam screens), UM will NOT be re-run for the new replacement procedure.

o    The UM Status, Resolution, Owner, UM Review Hours (and clock), and all authorization date timestamps for the original procedure are copied to the new replacement procedure.

·         If a new UM-required procedure code is added (i.e. a new line item is added to the order and it meets the rules to require UM), that procedure will be treated as a brand new UM procedure instead of re-using the original UM Required date.

o    The Status for this new procedure will have the initial UM Status (e.g., Received).

o    The Authorization Dates details (recently updated with Feature #27036) will populate as follows:

§  The Request received, Order created, UM required, and Last updated timestamps for the new procedure will all reflect the date/time when the new procedure code was added to the order.

§  UM complete will be blank.

§  UM review hours will be calculated based on the new procedure’s UM Required Date.

o    As with other procedures requiring UM Review and not in a Final UM Status, the order will now appear on the UM WL with a UM Required flag.

Configuration Instructions

No System Administrator actions are necessary to enable this feature.