CMS defines medical necessity/medical necessary as "
| "Services or supplies that: are proper and needed for the diagnosis or treatment of your medical condition, are provided for the diagnosis, direct care, and treatment of your medical condition, meet the standards of good medical practice in the local area, and aren't mainly for the convenience of you or your doctor." Definition Medical Necessity |
It Is Not the Medical Coder's Responsibility......
It is not the responsibility of the medical coder to make up a diagnosis to meet medical necessity, however, it is the responsibility of the medical coder to verify the diagnosis, select the correct code to he highest level of specificity, follow Coding Guidelines, follow coding instructions in the ICD-CM Tabular, use all available resources, and link the ICD-CM code to the CPT code correctly.
The Responsibility of Establishing Medical Necessity Belongs to the Ordering Provider
Documentation supporting the medical necessity such as diagnosis or procedure codes must be submitted with each claim. Without such evidence, the claim will be denied as being not medically necessary. The medical record must include documentation of the signs, symptoms, and conditions associated with the billed diagnosis and procedure codes. Documentation
Remember--
If it is not documented, it was not done
"Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements 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. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record."CMS & MEDICAL NECESSITY
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