Wiki Determining Medical Necessity for Non-Clinical staff- I need help understanding

[Janet Fairhurst]

How does Medicare judge medical necessity? The question has come up due to a Medicare audit review questioning medical necessity documentation pre-op evaluation encounters. confused

 

[ValerieBatesHoffCPCCPMA]

Medical Necessity - National or Local Coverage Determinations

E/M:
Medical necessity of a service is the overarching criterion for payment in addition to the
individual requirements of a CPT code. It would not be medically necessary or
appropriate to bill a higher level of evaluation and management service when a lower
level of service is warranted. 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. The service should be documented during, or as soon as
practicable after it is provided in order to maintain an accurate medical record.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R178CP.pdf

ALL other CPT and HCPCs:

Most of these rules are not found in the Medicare Statue and regulations.
They are set out in program manuals and National Coverage Determinations developed by CMS.

http://www.partnershipforsolutions.org/DMS/files/MedNec1202.pdf


Another informative article:
http://codapedia.com/article_559_Medical-Necessity-is-not-Medical-Decision-Making.cfm

 

[CodingKing]

I'm curious what you mean by non-clinical staff. You aren't billing for routine pre-op done over the phone prior to a procedure are you?


If this is related to pre-op, i'm not sure medically necessary is what they are looking at. Do you commonly add modifier 25 to E&M on same day as a minor procedures (0-10 day)? High utilization of modifier 24 on E&M day of or day before a major procedure? That could be what they are interested in. Was the E&M above and beyond standard pre-op and was this information properly documented are a hot issue