E/M Coding Alert - 2019 Issue 12
Reader Question: Focus ‘Medical Necessity’ for Billing
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Article Overview
This reader Q&A addresses medical necessity as it relates to claim payment and denial prevention. It summarizes how the AMA and CMS frame the concept, notes that payer-specific rules can differ, and discusses the importance of diagnosis reporting, documentation, and beneficiary notice practices for billing teams and physicians.
Why This Topic Matters
Medical necessity is a common reason for claim denials and financial responsibility disputes. Understanding the general framework and payer variation helps coders, billers, and providers better support claims and communicate potential noncoverage.
What You Will Learn
- How medical necessity is generally defined in the billing context.
- Why payer-specific coverage expectations can affect claim outcomes.
- How diagnosis reporting and documentation relate to medical-necessity review.
- When beneficiary notice processes may be relevant to potential noncoverage.
Who Should Read This
- Medical coders
- Medical billers
- Revenue cycle staff
- Physicians
- Practice managers
- Compliance staff
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