2012年9月11日 星期二

Using Medical Necessity Effectively When Coding Patient Visits


Proper billing and coding practices can make or break the financial well-being of a medical practice. Understanding the rules that pertain to billing and coding can increase the revenue generated for your practice and can alleviate concerns regarding level of service requirements.

Physicians spend years obtaining the education that is necessary to practice medicine, but the billing and coding of medical claims is not a standard part of the medical curriculum. The fact of the matter is, understanding billing and coding is as crucial to the financial well-being of your practice as your medical education is to the physical well-being of your patients. Whether your practice has an in-house employee handling your billing or you outsource your billing and coding to a professional agency, you as the provider are ultimately responsible for the level of care you provide to your patients.

The evaluation and management (E/M) codes used in medical billing can be a significant source of revenue for your practice. While you, as a physician, understand the concept of Medical Necessity and you believe that you are providing your patients with necessary medical care, why is it that you are denied payment for a visit or a procedure that is considered unnecessary by someone who is not a medical professional? How is it that this person can judge whether or not the treatment was necessary when they were not there at the time of the visit?

The idea of Medical Necessity is a cloudy concept. It is described in less detail than many of the other coding definitions. Because of this, you should familiarize yourself with the concept of Medical Necessity if you hope to avoid denied claims and delays in payments to your practice. If you want to prevent denied claims and payment delays, you must ask yourself some questions...

What Constitutes Medical Necessity?

There are three components to the E/M guidelines including the patient history, physical exams and medical decision making. The determining factor in the level of care that you provide to a patient is the Medical Necessity component. This is also the deciding factor in how that level of care is billed to the patient's insurance provider.

Different insurance companies may have specific definitions of Medical Necessity. Medicare guidelines are what most insurance companies follow in regards to paying a claim. According to Section 1862(a) (1) (A) of the Social Security Act, Medicare does not pay for services that are not reasonable or necessary for the diagnosis or treatment of an injury or an illness or to improve the functioning of a malformed body member.

The AMA Model Managed Care Contract is a sample contract used to help physicians negotiate with health plan providers. This contract suggests that the definition of Medical Necessity is services or procedures that a prudent physician would provide to a patient in order to prevent, diagnose or treat an illness, injury or disease or the associated symptoms in a manner that is:

a) In accordance with the generally accepted standard of medical practice.

b) Clinically appropriate in terms of frequency, type, extent, site and duration.

c) Not for the intended for the economic benefit of the health plan or purchaser or the convenience of the patient, physician or other health care provider.

What Does Medicare Say about Medical Necessity?

According to the Medicare Claims Processing Manual, Medical Necessity is defined as "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."

What this tells us is that a provider is allowed to bill as high as the Medical Necessity warrants as long as the physician properly documents the office visit and meets all of the History, Physical Exam and Medical Decision Making criteria. If, however, the care that is provided to a patient is above and beyond Medical Necessity, the physician can only bill as high as the Medical Necessity warrants.

Putting the Pieces Together

There is one determining factor when navigating the murky waters of Medical Necessity and that is having a clear medical reason to perform a service or procedure. If there is clear medical need for the service or procedure that you are performing, then the Medical Necessity requirements will be met. For example, if you have a patient who comes into your office with difficulty breathing, you would absolutely have to perform a comprehensive medical history in order to address the issue. Each component of that history, such as the ROS, HPI/CC and PMFSH would be needed to obtain clinically relevant information.

The HPI you perform would help you obtain the information needed regarding the patient's current condition including the duration and timing of the symptoms. The ROS would then help you determine which systems are being affected by the condition and which diagnoses could be considered. At this time you would also learn about risk factors that could contribute to the patients current condition. All of these components would be medically necessary in order to provide the patient with a proper diagnosis and effective treatment, thereby meeting the requirements of Medical Necessity.

Now, let's say the same patient comes back to your office for a follow-up visit a few weeks later after being treated in the hospital for pneumonia. The patient has no particular complaints and seems to be doing well. You would not be able to justify a comprehensive medical exam at this point because there would be no clear Medical Necessity to perform one.

As a rule of thumb, consider whether or not the services you perform will help you modify or contribute to a patient's current visit or therapy. If not, then it is not medically necessary and does not meet the Medical Necessity requirements.

Medical Decision Making vs. Medical Necessity

Many physicians confuse Medical Necessity with Medical Decision making. In order to eliminate this confusion, it is easiest to consider the Medical Necessity component as a part of the Medical Decision Making process.

There is no denying that Medical Necessity is a vague and poorly-defined concept. It is open to different levels of interpretation and, in the end, the final determination regarding whether or not something was medically necessary is up to an individual who is not even a medical provider and was not present at the time of the service. Because of this, it is important that you document the intensity of the visit as well as the key components in order to code your visits properly and maximize your practice's incoming revenue.




Dr. Adam L. Alpers, D.O. is a medical practice consultant and invites you to access and gain knowledge in enhancing your medical billing and coding by visiting our blog at http://www.medbillingncoding.com This program was developed for providers to gain quick and easy understanding of some of the most needed information in billing and coding. You do the work, now get paid for what you do. To Learn and Earn more. Please, check out our informative teaching today also at: http://www.medicalcodingcashsecrets.com

Copyright - Adam L. Alpers. All Rights Reserved Worldwide





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