As part of the prior authorization process, radiology benefit management (RBM) intake personnel and nurse specialists are given the exact wording when communicating with doctors’ offices: “what is the reason for your request.” To facilitate a quick approval, understand that several answers to this question may be adequate and correct but some answers are more likely to result in an approval “right out of the gate.”
Most providers know that Medicare and some insurance companies do not recognize the use of a diagnosis (or an ICD-10 diagnosis code) unless the diagnosis has been conclusively confirmed. For example, when a patient presents with right lower quadrant abdominal pain, Medicare does not permit using the diagnosis “rule out appendicitis (K35.2)” as a code to describe the office visit or even to support a simple CBC. After all, the diagnosis of appendicitis is only suspected, not yet confirmed. Rather, Medicare requires providers to use the less serious diagnosis code “abdominal pain” (R10.31) until a CT or other study has confirmed that the patient really has appendicitis. There is no ICD-10 code for “Rule out appendicitis” or “suspected appendicitis.”
Radiology Benefits Management (RBM) regulations are different. Unlike Medicare, RBM nurse specialists and medical directors DO want to know what diagnosis you are considering, RBMs want to know what suspicions you have and what clinical information supports the requested CT or MRI. Thus, as a radical departure from Medicare rules, RBMs would prefer if providers communicated any clinical “rule outs” or suspected diseases. So when your prior authorization liaison is asked the reason for the imaging study, a response “rule out appendicitis” or “suspected appendicitis” is more likely to result in an approval number than merely saying “abdominal pain”
Lesson #15: When calling an RBM for approval of an imaging study, your office will be asked for the reason for the request. Even without a confirmed diagnosis, your office liaison is allowed and (even encouraged) to answer that question with a “rule out…” or a “suspected” diagnosis, even if the diagnosis has not yet been confirmed.
Obtaining a quick authorization number is more likely if the RBM knows what condition you are suspecting, rather than a symptom.