The Centers for Medicare & Medicaid Services (CMS) announced a new government-wide initiative, MyHealthEData, that provides patients with control of their health data. MyHealthEData is a response to the Executive Order to Promote Healthcare Choice and Competition Across the United States, issued by President Trump last year. The initiative’s aim is to: Empower patients, so every American […]
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Documenting medical necessity
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Medical Alarm Emergency Alert Button
Perhaps you suffer from an ailment that leaves you prone to accidents? Maybe you are in a wheelchair and live alone? Medical alarms can be your friend in need as you reach emergency responders with the push of a button.
Medical alarms are available for the old and young alike. Anybody who may need emergency help and cannot do it on their own can use these systems.
The alarms come with 24/7 monitoring by qualified staff ready and able to aid you during your medical emergency. Set-up is quick and easy. The alarms consist of a base unit that can be activated remotely from a wireless alert button. Feel like a day outside in the nice weather? The range not only covers indoors, but outdoors up to 400 feet.
When you suddenly find yourself in need of emergency services if you are nearby all you need to do is depress the emergency button on your medical alarm console. You’re not near the console? Don’t be frightened – simply depress your panic button on your wireless alert device. The portable wireless panic button can be worn three different ways: as a pendant, bracelet or clipped to your belt. Each one is waterproof so you can wear them at all times: even in the shower, tub or pool!
How does the system work for you? When you activate the medical alert system by pressing your panic button, you are connected to staff ready to help. They will decipher your need and if no one answers their two-way communication, emergency vehicles are dispatched instantly. You will have your personal medical history on file to aid in your care.
There is nothing to worry about when the responders are called. They will be able to get to you quite easily. The EMTs will find you in your home, yard or wherever you were when you pressed your panic button. They will cater to you; you do not need to find them once they arrive.
The medical alarm system simply plugs into a power outlet and your home phone system and you’re ready to go! Put on your medical alert bracelet or medical alert necklace and you will begin to regain your independence. For added security in your health and well being, research the First Response Medical Alert System to ease your mind.
Greg Ribaudo is the Vice President of Operations at First Response Systems, Inc. First Response Systems, Inc is a leading provider of personal emergency response systems and medical alert pendants. First Response’s medical alarm systems feature a medical alert that is a high-tech, professional-quality, long range emergency medical alarm and personal panic button system from as low as .00/a day. Visit http://www.FirstResponseSystem.com for more information.
Mic-Key Button Replacement
So my provider completed the following procedure and I am not sure the proper code:
G12.21 ALS (amyotrophic lateral sclerosis) (HCC) (primary encounter diagnosis) – Under sterile conditions the Mic-Key button was replaced today without difficulty. 20F 3cm tube inserted and balloon inflated with 5 mL sterile water (recommended 5mL, max 10 mL). 60mL sterile water then infused through the G-tube site without difficulty, and without subsequent leakage from around tube site. Tube with more play, no longer retracted into the stomach wall with the pressure of balloon. Much more comfortable per patient
The current code I am looking at is 43760 — change of gastronomy tube, per-cutaneous w/o imaging or endoscopic guidance but when I read the detailed description it seems more complicated than what my provider did in office.
Further description indicates:
The physician changes a gastrostomy tube via per-cutaneous approach. No imaging or endoscopic guidance is utilized. If the old gastrostomy tube has been placed endoscopically, the physician must remove it by snaring and pulling it out through the mouth. A new tube is placed subcutaneously through the abdominal wall via the existing tract. A small incision is made through the skin and fascia. A large bore needle with suture attached is passed through the incision into the lumen of the stomach. The needle is snared and the needle and suture are removed via the mouth. The gastrostomy tube is connected to the suture and passed through the mouth into the stomach and out the abdominal wall. The gastrostomy tube is sutured to the skin.
Thank you!!
The Medical Necessity Hot Button
Clearing up the confusion surrounding Medical Necessity!
by Lori-Lynne A. Webb, CPC, CCS-P, CCP, COBGC, CHDA (originally printed through HCPro March 2017)
Understanding and determining medical necessity can be very complex for physicians, clinicians, coders, and billers.A physician or clinical provider of care may have a completely different understanding, interpretation, and definition of medical necessity than the patient or a patient’s family member. A third-party insurance payer may also have another completely different understanding and application of the term.
Defining medical necessity
So what is medical necessity? Coders or billers struggle to understand and sort out as the term, which leads to misinterpretation and misunderstanding of what needs to be communicated in a variety of areas.
CMS provides a specific definition under the Social Security Act:
… no Medicare payment shall be made for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
In essence, the diagnosis drives medical necessity. Coders need to understand the diagnosis itself, as well as what services or treatment options are available to the provider.
Third-party payers add more confusion
Medical necessity can also be confusing when it comes to who is going to pay for the procedure or services. Many third-party payers have specific coverage rules regarding what they consider medically necessary or have riders and exclusions for specific procedures. Third-party payers may have a specific exclusion for procedures that they consider experimental, unproven for a specific diagnosis, or cosmetic.
One example is a surgeon using a daVinci robotic surgical device to perform a laparoscopic surgery. Upon pre-authorization for the surgery, the insurance payer states it will not pay for the surgery if the daVinci is used. The insurer’s policy includes a rider that deems the daVinci as an experimental surgical device. However, if the physician uses a traditional laparoscopic or open procedure, the third-party payer would reimburse. In this case, the insurance carrier is not stating that the surgery is not medically necessary, just that it will not reimburse for this surgery if the robotic device is used.
Even if a particular procedure or service is considered medically necessary, some payers impose limits on how many times a provider may render a specific service within a specified time frame. For Medicare and Medicaid, these limitations are known as National Coverage Determinations (NCD) and Local Coverage Determination (LCD). Private payers may simply refer to this type of limitation as a policy guideline or policy exclusion or rider.
Within these guidelines, payers may define where or when they will cover a specific service, but may limit coverage to a specific diagnosis. For example, insurance policies may have a wellness or preventive care benefit, but may only cover one such visit per year. Some payers may only reimburse for a single Prostate-Specific Antigen (PSA) test per year. The payer may require a documented screening diagnosis in coordination with the test.
If the patient underwent a PSA test January 1, 2012, for screening, his insurance may not pay for another test until 365 days (or one calendar year) have elapsed. However, if the patient undergoes a PSA blood test for screening and the test results are abnormal, the clinician may decide another PSA test is needed. The coder must submit that claim as a PSA blood test with the appropriate diagnosis for a sign, symptom, or abnormality, not as a screening.
Documenting medical necessity
Medical necessity continues to be open for interpretation by all parties involved. Many third-party payers have created lists of criteria they use to interpret medical necessity. These lists do not necessarily reflect all options, but payers include this reference in their policy guidelines.
Most providers have not developed a comprehensive listing of medically necessary qualifiers, so coders and clinicians must focus on good documentation and coding accuracy to communicate the medical necessity of services accurately to payers. If third-party payers deny reimbursement for medical services, physicians, clinicians, and coders need to rely on the formal appeal process.
Medical necessity documentation from a physician or provider should include the following:
§ Severity of the “signs and symptoms” or direct diagnosis exhibited by the patient. This is our diagnosis driver, and multiple diagnoses may be involved.
§ Probability of an adverse or a positive outcome for the patient, and how that risk equates to the diagnosis currently being evaluated. This is the medical risk vs. gain.
§ Need and/or availability of diagnostic studies and/or therapeutic intervention(s) to evaluate and investigate the patient’s presenting problem or current acute or chronic medical condition. In other words, does the facility, office, or hospital have what the provider or clinician needs to render care?
These bullet points reflect the basics of evaluation and management (E/M) guidelines that are currently in place from CPT®: the history, exam, and medical decision making processes. Coders will have an easier time evaluating medical necessity from this aspect. Of course, a good understanding of this integration of medical necessity within the E/M guidelines makes communicating this same principle to the providers much easier. Coders should encourage providers to continually enhance their documentation to improve overall coordination between the medical record, coding accuracy, and third-party payer reimbursement.
The third-party payers employ a wide spectrum of policies defining medical necessity is and should encompass. Physicians, clinical providers, and coders should review what these payers have established within their guidelines. Someone within the physician office, hospital, or medical facility should thoroughly scrutinize these guidelines before establishing a contractual relationship with a particular third party payer. This up-front communication will help avoid claim denials in the future.
Here are some examples of what some third party payers are currently including in their medically necessary verbiage:
§ Treatment is consistent with the symptoms or diagnosis of the illness, injury, or symptoms under review by the provider of care.
§ Treatment is necessary and consistent with generally accepted professional medical standards (i.e., not experimental or investigational).
§ Treatment is not furnished primarily for the convenience of the patient, the attending physician, or another physician or supplier.
§ Treatment is furnished at the most appropriate level that can be provided safely and effectively to the patient, and is neither more or less than what the patient is requiring at that specific point in time.
§ The disbursement of medical care and/or treatment must not be related to the patient’s or the third party payer’s monetary status or benefit.
Documentation of all medical care should accurately reflect the need for and outcome of the treatment.
Treatment or medical services deemed to be medically necessary by the provider of those services,(e.g., physician, therapist, clinician, etc.) does not imply or infer that the service(s) provided will be covered by or deemed a medically necessary service payable by a third-party insurance payer.
Treatment or medical services deemed to be medically necessary by the provider of those services,(e.g., physician, therapist, clinician, etc.) does not imply or infer that the service(s) provided will be covered by or deemed a medically necessary service payable by a third-party insurance payer.
Medical Necessity Q&A
Q: Could you give me some guidance on how I can instruct my MD’s on avoiding vague and/or subjective clinical documentation?
A:. Ask your providers to adequately describe his/her skilled care providedand give a clear picture of the treatment and/or “next steps” to be taken.
Do not use vague or subjective descriptions like “tolerated treatment well,” “improving,” “caregiver instructed on med management,” or “continue with plan of care.” “patient is here for follow up”
examples of more complete and compliant statements:
1. Patient tolerated ROM exercises with a pain level of 6/10.
2. Patient was able to verbalize understanding and importance of checking their blood sugars prior to administering insulin.
3. Plan for next visit: to continue education on importance of daily inspection of feet for diabetic patient, provide wound care, etc.
Q I work in dermatology and need to know what documentation is required for excisions? We are struggling with getting paid
A: The provider should include the actual “size” of the lesion/mass they are going to excise. Then they should document the area of the excision which needs to include the lesion + any margins. (Height, Width, Depth) and if circular/elliptical etc… and denote the “why” it was performed that way. If you have to appeal, the problem with using strictly the sizes from a pathology report, is that tissue “shrinks” once it is excised, and the would “enlarges” once the tissue is excised.
Q. What is the BEST way to document our time spent… the CPT codes state a vague “time” amount but the doctors struggle with this..
A. Notation of Time in/Time out is always very helpful… it is also helpful if the provider “explains” the time. Eg – spent 20 minutes of our 30 minute visit discussing how to properly use their new asthma inhaler. Or I was requested by Dr. Doe for “standby” for a possible cesarean section during vaginal delivery. I entered the delivery room at 0800 and departed at 0915 status post a successful vaginal delivery.
Coders must understand the complex relationships between the physician, the patient, the medical record documentation, the coder, the biller, the insurance payer, and the communication between all of these entities to successfully guide the interpretation of medical necessity.