decisionhealth Newsletters, Coder Pink Sheets - 2007 Issue 12 (December)
Medical necessity guidelines help claims get paid
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Article Overview
This article discusses the role of medical necessity in claim review and payment, including how national and local coverage policies shape coverage determinations. It also distinguishes medical necessity from E/M medical decision-making and points readers to CMS and payer resources for staying current on policy changes. The content is aimed at coding professionals, billers, and revenue cycle staff who need to understand why claims may be denied and how coverage policy influences documentation review.
Why This Topic Matters
Medical necessity is a common reason claims are denied, so understanding the concept helps coding and billing staff support payment and respond to coverage scrutiny. The article highlights why policy awareness and documentation support matter across Medicare and commercial payer settings.
Article Sections
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Medical necessity and coverage determinations
Introduces the concept of medical necessity and explains its relationship to coverage policy and claim review. Discusses how payer and Medicare policies shape whether services are considered covered.
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Medical necessity vs. medical decision-making
Compares medical necessity with the E/M concept of medical decision-making. Notes the distinction between the reason a service is needed and the cognitive elements used in visit scoring.
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Resources
Lists sources for staying current with CMS policy updates and examples of payer reference materials. Emphasizes the importance of reviewing policy changes and local guidance.
What You Will Learn
- How medical necessity is used in claim review
- How coverage policies relate to medical necessity
- How medical necessity differs from E/M medical decision-making
- Where to look for CMS and payer policy updates
Who Should Read This
- Medical coders
- Billing staff
- Revenue cycle professionals
- Physician office staff
- Compliance staff
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