Cooper University Health Care in Camden, New Jersey, developed this checklist to help ensure it satisfies various requirements before billing for new technology/procedures and services,[1] said Compliance Manager Kerri McCutchin. For example, do physicians who will use the new technology possess the proper credentials? Have the billing codes been communicated to revenue cycle, the health information management department and a third-party coding company, if applicable? Contact McCutchin at mccutchin-kerri@cooperhealth.edu.
New Technology Questionnaire
Will augmentation of privileges be required? □ YES □ NO If yes, list privilege and attach any clinical white papers to be used in completion of Focused Professional Practice Evaluation plan:
_____________________________________________________________________________
What other resources will be required (e.g., radiology, surgical backup, intensive care unit bed requirement, respiratory therapy, pharmacy)?
_____________________________________________________________________________
Section II—Product/Equipment Use:
Please specify the procedures in which the new product or equipment will be used:
|
Procedure Code/DRG |
Description |
Est. Volume - Inpatient per Procedure |
Est. Volume - Outpatient per Procedure |
|---|---|---|---|
Are the procedures listed above reimbursed by Medicare? □ YES □ NO □ N/A
-
If yes, is there a Medicare national coverage determination (NCD) or local coverage determination (LCD) for the procedure/use of equipment? □ YES #___________ □ NO
(Please attach NCD or LCD)
Are the procedures listed above reimbursed by Commercial Insurance? □ YES □ NO □ N/A
-
If yes, is there a clinical use policy for the procedure/use of equipment? □ YES □ NO
(Please attach clinical use policy)
Specify the estimated impact on Length of Stay, if any:__________________ □ N/A
Other factors to consider in deliberations: ____________________________________________
_____________________________________________________________________________
Section III—The following information must be completed by the requesting physician, if applicable:
Do you or a member of your immediate family have any ownership or investment interest in the manufacturer, distributor and/or seller of the requested new product or equipment? If yes, please explain:
Do you or a member of your immediate family receive any type of compensation from the manufacturer, distributor and/or seller of the requested new product or equipment? If yes, please explain:
Do you or will you receive any discounts, business courtesies, or free goods or services from the manufacturer, distributor and/or seller of the requested new product or equipment in consideration of your use and/or promotion of this new product or equipment? If yes, please explain:
Physician’s signature:_____________________________________ Date:_______________________________
