Wiki Payment without Medical Neccessity Dx

Create Wiki
C

Cuteyr

Guru
Messages
133
Best answers
0
--------------------------------------------------------------------------------

Hi all,

I was taught that we should always code dx checking the NCD/LCD.

I could see that some of the charges are getting paid even if they dont have a proper dx that is in the LCD/NCD.(Medical Neccessity not met)

Could someone explain me why or how are these paid?

Thanks
 
Are all of the charges for Medicare patients? And are the dates of service in question falling within the effective dates of the LCD's? Not sure what other aspect to check...
 
Read the LCD/NCD carefully some them state ..... diagnosis SUCH AS .... and then lists some of the acceptable codes, by saying "such as" they leave the door open to allow dx codes other than what is listed.
 
Medical Neccessity

Thanks for the reply..Now i have a second doubt..Should we check the LCD/NCD only for Medicare patients ? is it ok if we send the claim with the dx not in LCD for private payers?
 
Each payer will set their own coverage guidelines. Most of the commercial payers we deal with aren't quite as strict as our MAC. For example, MRI of Lumbar Spine...Our MAC does not include Low back pain 724.2 as a medically necessary dx, but our commercial payers will allow it. Need to check each payers coverage guidelines, but most important, code appropriately from documentation, not just based on which diagnoses will "pay".
 
You must log in or register to reply here.
Top