PAHCS
CEUniversity
Packet #10-2013
This packet is worth 2 CEU
THIS PACKET CAN ONLY BE USED 1 TIME FOR A CEU.
Importance of Medical Necessity
Fax your answer sheet to 888-852-8468
or
email your answers to [email protected]
THIS PACKET CAN ONLY BE USED 1 TIME FOR A CEU.
PAHCS CEUniversity Packet #10-2013
Read the article below and then answer the questions at the end. Fax your answers
to 888-852-8468 or e-mail the answers to [email protected]
This Packet is worth 2 CEU
The Importance of Medical Necessity
ICD-9 codes represent the first line of defense when it comes to medical necessity.
Correctly chosen diagnosis codes support the reason for the visit as well as the level of
the E/M services provided. The issue of medical necessity is one of definitions and
communication. What is obvious to the physician may not be obvious to the coder or
those reviewing for medical necessity. It is how they get applied in the claims process,
particularly where evaluation and management (E/M) services are concerned.
The Medicare Claims Process Manual says that medical necessity is the “overarching
criterion for payment in addition to the individual requirement of a CPT code. It would
not be medically necessary or appropriate to bill a higher level of evaluation and
management service when a lower level of service is warranted. The volume of
documentation should not be the primary influence upon which a specific level of
service is billed. Documentation should support the level of service reported.”
When it comes to selecting the appropriate level of care for any encounter, medical
necessity trumps everything else in the documentation. Even if you documentation
contains all the elements for a higher level code it will not ensure that it withstand an
audit if the medical necessity is not there.
The following are some strategies to help make your coding for medical necessity
easier.
Link each ICD-9 code to the appropriate CPT code. On your claim forms, make sure
it’s clear which diagnosis codes correspond with which services. This will show health
plans why it was medically necessary for you to perform the services you did.
Include a fourth or fifth digit to more accurately describe your patient’s
condition. Consider a patient with chronic obstructive pulmonary disease (COPD) that
is not controlled on current inhalers. The physician decides to add a steroid inhaler to
current therapy. You could report the encounter using only the ICD-9 code for COPD,
496, “chronic airway obstruction, not elsewhere classified,” but a more descriptive
approach would be to code 491.21, “obstructive chronic bronchitis with acute
exacerbation.” This code specifically identifies the patient as having some elements of
chronic bronchitis, COPD and emphysema, and indicates that these clinical problems
are not controlled.
List ICD-9 codes, beginning with the primary diagnosis. The standard billing format
for Medicare has room for four ICD-9 codes to describe the encounter. When
appropriate, you should fill all four slots. The code that describes the primary diagnosis
or reason for the visit should appear first, followed by codes for other diagnoses listed in
descending order of importance. Choose the codes that best describe the context and
severity of the clinical problems addressed at that visit, keeping in mind that “suspected”
or “probable” diagnoses should always be omitted. For example, let’s say you are
submitting a claim for a level-5 office visit (99215) and the only ICD-9 code you report is
for congestive heart failure (428.0). You can guarantee that this encounter will be
scrutinized in terms of medical necessity. However, if in the progress note orthopnea,
hyponatremia and edema are also indicated then consider reporting the same CPT
code with the following four ICD-9 codes:
• 428.23, acute on chronic ;
• 786.02, orthopnea;
• 276.1, hyponatremia;
• 782.3, edema.
These codes would convey the information that the encounter took place to treat
orthopnea due to an acute exacerbation of chronic systolic congestive heart failure and
that the patient also had hyponatremia and edema.
Learn which codes you use together most frequently. There are certain codes that
convey information in clusters. These code sets are often used to describe common
clinical problems that frequently occur together. For instance, the following code set
might be used for diabetics with kidney disease:
• 250.42, diabetes with renal manifestations; type 2 or unspecified type,
uncontrolled;
• 585.4, chronic kidney disease, stage IV (severe);
• 791.0, proteinuria;
• 285.21, anemia in chronic kidney disease.
The first code is a “power code” that signifies that the patient has type-2 diabetes
mellitus that is poorly controlled and has led to renal insufficiency. The other codes
explain that this has led to severe renal compromise. They also show that the patient
has proteinuria and renal anemia. You can be more comfortable submitting a level-IV or
level-V office visit for these codes than for the single code 593.9, “unspecified disorder
of kidney and ureter.” For another example, consider a patient with diabetes, open
wounds of the toes and no pedal pulses. You might code the following:
• 250.80, diabetes with other specified manifestations;
• 250.70, diabetes with peripheral circulatory disorders;
• 707.15, ulcer of toes;
• 443.81, peripheral angiopathy.
In addition to implementing diagnosis coding strategies, you also need to be aware of
Medicare’s National Coverage Determinations (NCDs) and Local Coverage
Determinations (LCDs). These rules specify the services that are allowed for certain
diagnoses. NCDs are Medicare’s standard national codes. LCDs are local carriers’
versions of NCDs. LCD’s can change frequently, causing frustration, so to keep up-todate check you local Medicare web site often. Private payers can create their own rules
when it comes to allowing certain services with certain diagnoses. You can check the
payer websites for their determinations.
If there are multiple clinical issues during an encounter, make sure this is reflected in
your ICD-9 coding this will help ensure fewer claim denials. One important thing to
remember is DO NOT use a diagnoses code that is not listed in the medical record just
because the insurance determines it is appropriate for the procedure code you are
billing for in order to get the claim paid.
THIS PACKET CAN ONLY BE USED 1 TIME FOR A CEU.
Fax this answer sheet to 888-852-8468
or
email your answers to [email protected]
CEUniversity Package # 10-2013 for 2 CEU’s
Importance of Medical Necessity
NAME: _______________________________________ MEMBER #______________
E-MAIL ADDRESS: ______________________________________________________
_____1. The first line of defense in medical necessity is
a. HPI
b. CPR
c. ICD-9 codes
d. P4P
_____2. The manual used to explain medical necessity is
a. CPT
b. Medicare Claims Manual
c. HCPCS
_____3. To make coding for medical necessity easier
a. Select the appropriate CPT code
b. Select a place of service
c. ICD-9 linkage
d. a and c
_____4. To more accurately describe the patient's condition include
a. Signs and symptoms
b. HPI
c. 4th or 5th digit ICD-9 code
_____5. If there is a complicated office encounter and it is supported with documentation it is
best to
a. List only the main diagnosis
b. List the suspected or probable diagnosis
c. List primary diagnosis with any others documented
_____6. The Medicare rules that specify the services allowed for certain diagnoses are
contained in
a. National Constitution Determination and Local Coverage Determination
b. National Coverage Determination and Local Coverage Determination
c. National Constitution Determination and Local Calculated Determination
_____7. If you see patients with frequent common clinical problems a good coding
strategy would be to
a. Use codes that convey information in clusters
b. Have the patient come in for weekly visits
c. Select the highest level E/M code
_____8. The best way to withstand an audit is t
a. Hire a good attorney
b. Be sure medical necessity is always met
c. Only use EMRs
_____9. The standard billing format for Medicare is four slots. The code that describes
the reason for the visit should appear
a. Third
b. First
c. Second
d. Fourth
_____10. One thing to remember when coding for medical necessity is
a. Always code what is documented
b. Always code what the insurance company will pay
c. Always code the highest E/M level
d. Always code four diagnosis