The problem is that determining medical necessity is not always easy. and payors, which, in turn, can result in the care provided not meeting the definition. The diagnosis reported helps support the medical necessity of the it is on the approved list of diagnosis codes that meet medical necessity. Medical necessity is the primary criterion that is considered in determining whether a health care Medically necessary care must meet the following criteria.
They misunderstood what I meant when I said that the office visit didn't support the medical necessity for the level coded or that the brain MRI ordered for lung cancer wasn't medically necessary. The Social Security Act's definition of medical necessity is all about payment and not necessarily about patient care. It's an important distinction, especially from a compliance and coding perspective, and one that must be made clear in discussions with providers. Nuts and Bolts What information do providers need to supply in order to support medical necessity?
In short, documentation that links the patient's chief complaint with any problems found and a list of comorbidities that affect care, complicate treatment, or add detail to explain the actions being taken. In the EHR era, these visit types have taken on even greater importance from a coding perspective. Coders know the three key components of history, exam, and medical decision making MDM usually determine the level of service a provider may bill.
The Essentials of Medical Necessity
When the documentation guidelines were introduced inconsultants often told providers to count on their fingers and toes when determining history and exam. They used bullet points to account for the updated documentation guidelines, then spent a brief time talking about MDM before moving on to selecting the level of service. They frequently glossed over the link between MDM and medical necessity because it "only really mattered" for new patients, admissions, or consultations in which all three of the key components must be met or exceeded for coding.
The MDM criteria were not a priority because they were too ambiguous to explain to practitioners or fellow coders. The arrival of EHRs and their easy-to-check-off boxes introduced problems associated with cloning and overdocumentation of history and exams. Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code.
The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. Consequences What does this edict mean and how is it applied? In short, patients visit physicians to be treated and healed. The goal of this documentation is, of course, to support medical necessity. Too often this method leads to documenting a large number of review of systems as well as the complete family and social histories.
There are almost as many definitions of medical necessity as there are payors, laws and courts to interpret them.
Generally speaking, though, most definitions incorporate the principle of providing services which are "reasonable and necessary" or "appropriate" in light of clinical standards of practice. The lack of objectivity inherent in these terms often leads to widely varying interpretations by physicians and payors, which, in turn, can result in the care provided not meeting the definition.
For example, Medicare defines "medical necessity" as services or items reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. While that sounds like a hard and fast rule, consider that CMS formerly HCFA has the power under the Social Security Act to determine if the method of treating a patient in the particular case is reasonable and necessary on a case-by-case basis.
Even if a service is reasonable and necessary, coverage may be limited if the service is provided more frequently than allowed under a national coverage policy, a local medical policy or a clinically accepted standard of practice. If Medicare or other payors determine that services were medically unnecessary after payment has already been made, they treat it as an overpayment and demand that the money be refunded, with interest.
Moreover, if a pattern of such claims can be shown and the physician knows or should know that the services are not medically necessary, the physician may face large monetary penalties, exclusion from Medicare program, and criminal prosecution. Protections Against Denial Considering the potential financial and legal liabilities tied to mistakenly filing a claim the physician believes to be medically necessary, the question becomes what can be done to protect against claims which are denied because they are for unnecessary services.
Obviously, the best way to protect yourself is to avoid the denial in the first place.
Here are some solutions to the problem. You should have known. Ignorance, however, is not a defense because a general notice to the medical community from CMS or a carrier including a Medicare Report or Special Bulletin that a service is not covered is considered sufficient notice. Courts have concluded that it is reasonable to expect physicians to comply with the published policies or regulations they receive.
Thus, no other evidence of knowledge may be necessary.
Physicians can obtain up-to-date information on services covered by Medicare from several sources. These quarterly updates include all changes to Medicare instructions that affect physicians, provide a single source for national Medicare provider information, and give physicians advance notice on upcoming instructions and regulations.
In addition, CMS maintains an official list describing approximately covered items, services and procedures in its "Coverage Issues Manual". This information can be found on a website maintained by CMS at www.
Carrier bulletins also include coverage notices which provide another way to stay current. CMS recently changed the requirement that physicians had to register with their carrier to get free carrier bulletins sent to their practices. Now carriers will automatically send them unless the physician has not billed Medicare for at least 12 months.
Make the patient responsible for payment.
What is medical necessity?
If the physician believes that Medicare will deny a service on the basis of medical necessity, the patient should sign an advance notice which identifies the non-covered service before the service is rendered.
This makes the patient responsible for payment if the service is denied.
However, at the present time, the final rules for using this revised form have not been published. When finalized, use of these approved forms will become mandatory.