BC Advantage - 2009 Issue 11

Common Concerns When Coding Evaluation and Management Services

Evaluation and Management (E/M) services-an important revenue source for providers nationwide-have long been under scrutiny by payers and government agencies. Most denials and payer reviews that result in down coding or recoupment of funds are due to lack of documentation to support medical necessity. As such, it is imperative that providers understand how CMS and other payers define medical necessity.Medical necessity encompasses the patient's need for care, as recorded in the chief complaint, physical observations, and the amount of necessary work performed by the provider through data review, diagnostics, orders, and treatment planning including anticipated progress or outcome...

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