MMO Basics
Cohere Commercial Policy, MCG
Commercial Hierarchy
First choice for diagnosis of arrhythmias
Holter Monitor
What are the different types of EGDs?
(hint: think current symptoms, treatment of symptoms, monitoring of symptoms)
Diagnostic, Therapeutic, and Surveillance
What types of therapy do we review for in MMO?
Physical Therapy, Speech and Language Therapy, Occupational Therapy
Oral cavity, Throat, Voice box, Paranasal sinuses, nasal cavity, and Salivary glands are all considered what kind of cancer?
Head and Neck Cancer
Medicare Hierarchy
Coronary Artery Disease (CAD)
Done to diagnose obscure gastrointestinal bleeding when an EGD and Colonoscopy failed to find the source of the bleeding.
Capsule Endoscopy
Considered a type of complementary and alternative medicine, this involves a licensed practitioner who uses their hands to manipulate the spine and other parts of the body to treat musculoskeletal problems.
Chiropractic Care
The following types of CT requests are considered approvable at the RN level when the patient is going through cancer treatment.
CT Chest, Abdomen, Pelvis and/or Brain
You receive a retro-request, how do you review?
Admin Void "Responsibility of a non-Cohere review organization"
What report is required prior to approving a Percutaneous Coronary Intervention (PCI)?
Cardiac Catheterization Report
A comprehensive diagnostic sleep test including at least electroencephalography (EEG), electro-oculography (EOG), electromyography (EMG), heart rate or electrocardiography (ECG), airflow, breathing/respiratory effort, and arterial oxygen saturation (SaO2) furnished in a sleep laboratory facility in which a technologist supervises the recording during sleep time and has the ability to intervene if needed
Polysomnography
We calculate number of visits for therapy using what? (hint: these can be listed on both the service request and within the clinical documentation)
Diagnosis codes
When reviewing PET scans for cancer indications, what is required? (Hint: If we don't have this we would pend to MI)
Tissue Biopsy results/Tissue diagnosis
When do we offer a P2P for a Commercial request?
In the Denial Letter - Post Denial P2P offer
"This procedure is clinically unproven and not medically necessary. There is inconclusive evidence of its effectiveness.” (hint: CPT C1761 and 92972)
Coronary Intravenous Lithotripsy
Can be used for a split night study or for PAP titration (hint: this is a specific CPT code)
When calculating the maximum allowable number of visits we use ____ guidelines and choose the ___%ile number of visits.
MCG, 50th
What is important to note when reviewing imaging for extremity requests?
Body part (this points to the correct criteria on the guideline)
A provider is Out of Network (OON), but there is no OON review...
Reach out to nursing leadership so that the case can be sent back to intake for an OON review.
Where do we go to confirm if a Facility is registered to perform Carotid Stents, Watchman procedures, TAVR, Mitral Valve Replacement, etc?
Quality Improvement for Institutions - Participant Directory (Link in work instruction)
What is the main difference between the following CPT codes: E0485 vs E0486 (hint: These are oral appliances)
E0485 - prefabricated
E0486 - custom-made
Pend to MD - we do not Nudge for CPT codes for MMO
A 3D imaging code [CPT 76376, 76377] is submitted WITH an MRI/CT request and the MRI/CT, how do we review?
If the MRI/CT is approvable at the nurse level, then we can also approve the 3D imaging code at the nurse level.