It is the responsibility of CMS to administer Medicare
and other federally mandated healthcare programs throughout the United
States. Medicare prohibits payment for services and items deemed by local
Medicare Carriers as not medically reasonable and necessary for the diagnosis
or treatment of an illness or injury, so here documentation is essential for
claims to be paid.
There are a couple of points that a physician needs to
ensure like only tests that are medically necessary in diagnosing or treating
their patients should be asked for, correct ICD-9 codes to be used for patient
files and test request forms, advance beneficiary notes to be signed by
patients in
case service gets denied.
case service gets denied.
Coders often overlook medical necessity in the evaluation
and management (E/M) code assignment process. Medical necessity is a difficult
concept for most coders to grasp and apply on a consistent basis in the E/M
assignment process.
Definitions of medical necessity vary – depending on whom
you are – physician, coder, biller, payer. Clear and to the point medical
record documentation is critical to providing patients with quality care and is
required in order for providers to receive accurate and timely payment for
furnished services. It is also used to document all the care the patient
receives and all the facts and findings related to him. Medical record
documentation assists physicians and other health care professionals in
evaluating and planning the patient’s immediate treatment and monitoring the
patient’s health care over time.
Depending upon the type of history taken, extent of the
physical exam performed, and the degree of decision-making required, specific
office E/M codes are assigned by the coder. If the physician has overlooked any
detail in the documentation of a past family and social history or ROS, the
coder may seek clarification and documentation of these missing elements and
proceed to assign a specific E/M code.
CMS
Documentation Guidelines for providing medical necessity ensures that
coders code correctly and the set of guidelines can be used for hospital
training. Coders play an important role in educating physicians on the
importance of documenting medical necessity that supports E/M code assignment
for the services they perform. They also provide feedback to physicians to keep
them updated of all the changes and avoid possible errors. Coders can also
encourage physicians to bill when it is utterly important. The patient’s
condition, severity, acuity, number of problems, etc., is critical in
determining medical necessity for Medicare payment for services. The E/M code used
must define the patient’s needs, work performed, and medical necessity. When an
E/M service is coded with a high level based on the documentation of key
component work, Medicare payment should not be asked for when the patient’s
effective management does not require the code’s work. By adhering to these
principles, physicians and coders can reduce potential financial reimbursement
liabilities and allegations of over-documenting and upcoding.
If you are looking for online
medical coding training conferences, AudioEducator is the place where you can
choose a wide range of medical coding conferences that includes topics on CMS’
Documentation Guidelines as well as helps you to train by providing conferences
that covers topics like CMS
hospital training guidelines and much more!
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