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When ICD-10-CM is updated Oct. 1, so are these National Coverage Determinations. Are you wondering which National Coverage Determinations (NCDs) will be affected by the thousands of diagnosis code changes going into effect Oct. 1? A Centers for Medicare & Medicaid Services (CMS) transmittal tells all. CMS Transmittal 11546, issued Aug. 4, is a one-time […]
The post Check NCDs for Medical Necessity Code Changes appeared first on AAPC Knowledge Center.
Come to terms with payers to protect your provider’s revenue stream. “Medical necessity” is an important concept for medical coders and auditors to understand. Health insurance companies (payers) use criteria to determine whether items or services provided to their beneficiaries or members are medically necessary. As a rule, payers will not reimburse for medical procedures, […]
The post Medical Necessity: Is It Really Necessary? appeared first on AAPC Knowledge Center.
The quality of evaluation and management documentation is paramount for clinician reimbursement. Evaluation and management (E/M) services are the most vulnerable to billing errors because it is complicated to select the proper code for the level of service captured in the documentation. A firm grasp of the differences between medical decision making (MDM) and medical […]
The post Fortify Your Understanding of Medical Necessity appeared first on AAPC Knowledge Center.
“Medical necessity” is difficult to define, with as many different interpretations as there are payers; however, most definitions incorporate the idea that healthcare services must be “reasonable and necessary” or “appropriate,” given a patient’s condition and the current standards of clinical practice. Yet typically, the decision as to whether services are medically necessary is made […]
The post Medical Necessity: Why It Matters, Ways to Demonstrate It appeared first on AAPC Knowledge Center.
HISTORY OF PRESENT ILLNESS: ….. is a 55-year-old male who
comes to the office on 01/31/2019 for a followup for a
colonoscopy. The colonoscopy, the patient states that he had a
good prep. It did not make him sick. He does not remember the
procedure, and he had no ill effects from the procedure. He is
in zero type pain at the present time.
PHYSICAL EXAMINATION: General: Demonstrates a 55-year-old
white male, oriented x3, pleasant and cooperative.
Vital Signs: Temperature 97.6, pulse 57, respirations 20, BP of
132/78, 6 feet tall, 248 pounds, 97% on room air. 0 pain at the
present time.
Lungs: Clear to auscultation bilaterally. No rales, rhonchi or
friction rubs. No wheezing. Normal respiratory effort. No
shortness of breath.
Heart: Regular rate and rhythm. No S3 or S4 sounds are heard.
No chest pain during the examination. No bruits heard over the
carotids or aorta. No swelling to the lower extremities.
Abdomen: No masses in the abdomen. No tenderness. No
organomegaly. No evidence of hernia.
We reviewed the following material for this visit.
CURRENT MEDICATIONS: We reviewed his medication list.
IMAGING: We reviewed the chest x-ray from 01/04/2019.
LABORATORY: We reviewed his blood work from January 4, 2019.
We reviewed his colonoscopy from 01/25/2019, which demonstrated
2 polyps. We reviewed the pathology report from 01/25/2019,
which demonstrated the 2 polyps to be adenomatous polyps. One
is a pure adenoma, the other one was a tubular adenoma. No
evidence of dysplasia, metaplasia or cancer.
We reviewed the consultation from 01/02/2019.
IMPRESSION: We have a healthy 55-year-old white male who grows
adenomatous polyps.
RECOMMENDATIONS: A repeat colonoscopy in 2 years.
Know what payers are looking for in subsequent hospital care claims, and how to give it to them. Medical necessity is the No. 1 consideration when selecting an evaluation and management (E/M) service code. Without medical necessity to support billed services, your practice is put at a serious noncompliance risk. Consider, for example, one payer’s […]
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Has anyone else been getting denials for 93005 and 93041 for not meeting medical necessity. There is no current policy. Not sure what DX codes would meet medical necessity.
Help!