decisionhealth Newsletters, Coder Pink Sheets - 2007 Issue 11 (November)
Medical necessity guidelines help claims get paid
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Article Overview
This article explains the general concept of medical necessity and why it is frequently used in claim review and denial decisions, especially in ophthalmology. It is aimed at coders, billers, and practice staff who need a high-level understanding of how CMS coverage policy, payer determinations, and E/M documentation concepts relate to reimbursement. The article also points readers to CMS and payer resource sites for staying current on policy updates and related guidance.
Why This Topic Matters
Understanding medical necessity is important because it affects whether services are considered covered and supported in claim review. The article helps readers distinguish this concept from E/M medical decision-making and highlights the need to monitor coverage policy updates.
What You Will Learn
- What medical necessity means in the context of coverage review
- Why ophthalmology services are often evaluated under medical necessity standards
- How medical necessity differs from E/M medical decision-making
- Where to find CMS and payer resources related to coverage guidance
Who Should Read This
- Medical coders
- Billing staff
- Ophthalmology practices
- Practice managers
- Revenue cycle teams
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