Medicare Compliance & Reimbursement - 2021 Issue 7
Back to Basics: Use Knowledge of Medical Necessity to Better Your Documentation
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Article Overview
This article explains how medical necessity is used in coding and documentation, especially in the context of office and outpatient evaluation and management services. It is written for coders, auditors, compliance staff, and clinicians who need to understand how documentation supports payment, how payer policies can differ from clinical standards, and how coding accuracy is affected when diagnosis information alone is not enough.
Why This Topic Matters
Understanding medical necessity helps readers recognize why documentation must support the services reported and why payer-specific coverage criteria can affect reimbursement. The article is relevant to anyone preparing, reviewing, or auditing records for office/outpatient E/M and related procedure claims.
What You Will Learn
- How medical necessity is generally defined across major medical and payer perspectives
- How medical necessity relates to office and outpatient E/M documentation
- Why payer policy and clinical judgment may not always align
- How diagnosis information can affect procedure and treatment reporting
- How documentation can better support the rationale for ordered or performed services
Who Should Read This
- Medical coders
- Coding auditors
- Compliance professionals
- Physicians and other clinicians
- Revenue integrity staff
- Billing staff
Codes Discussed
Code Ranges Discussed
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