Join today! Academy members receive many benefits for professional development, practice management, and community development. Facebook Twitter Linkedin Youtube Instagram. Not all diagnoses for all procedures are considered medically necessary. Medicare and commercial payers have coverage policies that specify the diagnosis codes that support medical necessity for certain procedures.
Also included in the coverage policies are documentation requirements. The documentation requirements can include diagnostic test values that must be met, that less invasive treatments be attempted before the service is determined to be medically necessary, or - for a repeat procedure - a statement of the outcome of the previous procedure of the same type.
Knowing the coverage polices for the services provided in your office can help eliminate denied claims later. The coverage policies are available for providers to review and adhere to when submitting claims. The coverage policies for Medicare are found at the Medicare Coverage Database. Private payers e. Cigna, United Healthcare, etc. Most private payers have their coverage polices available on their website.
Provider contracts with payers also include coverage policies. If the service is not covered by a particular payer, the patient should be informed prior to performance of the service. Another problem area is unspecified diagnosis codes, which can be an audit trigger if more specificity could be coded.
For example, if a patient has congestive heart failure and is seeing a cardiologist in follow-up, it is important for the physician to document and code the type of heart failure to support medical necessity. Many times in documentation we see CHF without elaboration. Coders need to be more vigilant to query practitioners whose documentation lacks specificity. Think about it: if specificity is lacking, could a payer consider the encounter an illegitimate visit or a procedure that was not medically necessary?
A situation I see much too often when performing audits is lack of laterality in coding an encounter. For example, if a patient has otitis media and the physician selects H Sometimes the type of otitis might not be able to be identified initially, but the ear affected should be documented and coded.
This type of error could trigger a payer audit unnecessarily. One example I run across frequently in OB care is failure to code the weeks of gestation for a pregnancy Z3A. This information might be important to a payer, and a claim could be denied based on the lack of this important information. The procedure and diagnosis must make sense together. In both examples it is clear that medical necessity is not supported. Take one last minute before submitting the claim and make sure the procedure and diagnosis links correctly.
I sometimes run across coders asking me what the payable diagnosis for a procedure or service is. This is not compliant practice. A coder or practitioner should never code a claim based on payer policy. If the service is not covered based on the diagnosis code, the patient should be informed that they will need to pay for it. For Medicare, the ABN is an important document that must be signed for a procedure or service that might not be covered, allowing the patient to decide if they wish to proceed.
If the ABN is not signed, the patient will not be responsible for payment of the service. Reporting a diagnosis that the patient does not have solely for the purpose of obtaining reimbursement for a service can be construed as fraud and likely will result in fines, penalties, and in some cases, even criminal prosecution. Some payers have a list-serv or alerts that you can subscribe to for receiving updates. Patient Advocate Foundation.
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