MRA Thought of the Day – Finding Support for Medical Necessity in Outpatient Services

Cathie Wilde, RHIA, CCS - Director, Coding Services Medical Coding Leave a Comment

Cathie Wilde, RHIA, CCS, Vice President of Coding Services Cathie Wilde, RHIA, CCS, Vice President of Coding Services

Do the diagnosis codes that you submit on your claims support medical necessity? When you are coding patient encounters, do you assign diagnosis code(s) based only the final diagnosis documented by the provider, or do you review the record for chronic conditions that are being followed and should also be coded?

CMS, and other local insurance carriers, have medical coverage policies (LCD, NCD, etc) for certain ancillary services, such as EKG, lab and radiology. The policies outline coverage criteria (diagnosis) for ancillary services. And some of these criteria lie beyond the final diagnosis.

Here are my thoughts…

  • First, review the documentation, assessment and treatment plan.
  • Know the type of insurance the patient has and familiarize yourself with their coverage policy. If you’re not sure, review their website. Most payers post their specific medical coverage policies on their websites.
  • Review the list of diagnosis codes that would cover the service(s) performed.
  • Review the provider’s documentation for additional signs, symptoms or diagnosis that are being treated and should be coded in accordance with official coding guidelines.
  • Assign diagnosis codes based on the final diagnosis documented by the provider as well as any chronic conditions that require ongoing treatment and follow up.

Example; a patient presents for a “yearly physical” and the provider orders lab work to monitor the patients’ chronic conditions, but the chronic conditions are not coded. The lab test may not be covered if V70.0 (routine general medical exam), is the only diagnosis code reported.

What are your thoughts?

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