Documentation of Medical Necessity - JF Part A
Documentation and Coding that Demonstrates Medical Necessity
Only the documentation found in the patient's medical record should lead coders to the diagnosis(es) relevant to a claim. Given the many physiological elements or even organ systems involved in most conditions, it is commonly the case that a patient's clinical condition legitimately may be described in a number of different ways, at a number of different levels, and by a number of different (and all reasonable) code selections. Diagnosis and other coding systems reflect this complexity in their tightly inter-related hierarchical classifications of disease.
Medicare uses NCDs and LCDs to clarify coverage and the related coding that indicates medical necessity so claims may be paid correctly "the first time" and beneficiaries continue to have access to the services they need. Providers are encouraged to familiarize practitioners and reimbursement personnel with these coverage policies. Familiarity with Medicare coverage determinations should help the practitioner to document the elements of a patient's condition, or describe a service or drug delivered, in terms that allow a coder to find any appropriate diagnosis listed in an NCD or LCD.
As long as the documentation reflects the reality, the coder will not be led to an inappropriate diagnosis. Similarly, a coder's familiarity with NCD or LCD coding requirements promotes correct billing since these coverage determinations are written to assist the coder search for the specific conditions that allow claim reimbursement.
The codes listed in an LCD or in related coding articles must be present on a claim to allow the processing system to identify medical necessity for a specific service. Neither the LCD nor articles related to specific medical coverage define correct coding for the entire claim or all necessary coding elements.
Only Medicare Guidelines are Followed
In addition, while Medicare usually follows the Current Procedural Terminology (CPT) coding guidelines, these particular coding guidelines are generic and may be accepted and applied differently by the various insurers. At its discretion or as required by regulation, Medicare allows some codes and follows some guidelines that other insurers may not. Conversely, Medicare may disallow some codes and prohibit the use of some guidelines that may be required by other insurers.
If there is an NCD and/or LCD related to a particular item or service, the NCD/LCD only defines the Medicare coding for that specific item or service that establishes medical necessity, regardless of the existence of other guidelines.
Not all CPT/HCPCS codes will be detailed in NCDs or LCDs with readily available instructions or coding guidelines. If a coder does not find guidance in the coverage determinations, Noridian recommends the provider consults coding workgroups and CPT, HCPCS, and/or ICD-10 descriptors for coverage guidelines found in the American Medical Association (AMA) manuals.
Finally, understand that the Noridian Provider Contact Center (PCC) customer service representatives (CSRs) are not trained in medical claims coding and cannot provide assistance in how a particular claim should be coded. Per CMS direction, the phone lines answered by the CSRs are specifically dedicated to handle "general questions related to billing, claims, eligibility and payment."
- CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Local Coverage Determinations
- American Medical Association (AMA) Current Procedural Terminology (CPT) Manual
- Healthcare Common Procedure Coding System (HCPCS) Manual
Last Updated Mon, 31 Oct 2022 15:20:01 +0000