Outpatient Facility Coding Alert - 2019 Issue 9
Reader Question: Know How to Determine Medical Necessity
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Article Overview
This article addresses a common claim-denial issue: how medical necessity is defined by major organizations and how payer interpretations may differ from a treating physician’s view. It is relevant for practices, coders, billers, and compliance staff who need a general understanding of the policy and coverage context surrounding denied services. The discussion focuses on broad definition sources, including AMA and CMS references, and on why medical necessity determinations can be subjective.
Why This Topic Matters
Medical necessity is a frequent basis for claim denial, so understanding the broad sources of payer and policy definitions can help practices interpret denials and recognize why coverage decisions may vary.
What You Will Learn
- How major organizations frame the concept of medical necessity
- Why payer determinations may differ from a physician’s clinical judgment
- What general legal or policy sources are commonly used when evaluating medical necessity
- Why medical necessity can be a subjective coverage issue
Who Should Read This
- Medical coders
- Billers
- Practice managers
- Compliance staff
- Physicians
- Revenue cycle staff
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