medical necessity

  1. 5

    Anesthesia with pain procedures

    Hello, How do you handle the medical necessity for anesthesia on a procedure that per the LCD, anesthesia is not routinely necessary for the procedures? I think our office needs to have a form or something that documents the reason anesthesia is required for the procedure. Does any one have...
  2. J

    Answer Is Medicare LCD based on where patient lives or where service is provided?

    My understanding is that the Medicare LCD for a given procedure is based on where the procedure is performed, such that, for example, if a patient lives in Novitas jurisdiction, but travels to and has a procedure performed in a Palmetto jurisdiction, the medical necessity for the procedure...
  3. D

    Dx in A&P

    Good Morning All, When we have a diagnosis that is documented in the A&P only the education team in my office is split on whether or not this is "dingable". I haven't been able to find any guidelines that says ya or nay on this topic. Any help with included resources/guidelines would help us...
  4. A

    Medically Necessary Contact Fit and Materials

    Trying to figure out the best way to bill and receive reimbursement for scleral contact lenses. My doctor wants to use 92313 with H18.59 diagnosis, but Medicare allowable reimbursment is only $90.71. With contact lenses the total charge will be $2500.
  5. N

    x-ray medical necessity

    A hip x-ray was performed and a diagnosis obtained. However, in the chief complaint and the HPI there is only mention of the patient's knee. Is this a medical necessity issue? The patient technically came in for his knee so is the x-ray of the hip allowed to be billed? Thank you.
  6. H

    Help Finding ICD-10 Codes for Medicare

    Hi, I need help finding ICD-10 codes for a Medicare patient. Our provider feels she needs IV Vancomycin due to a bacteria infection. We have had trouble getting intravenous antibiotics for her in the past. How can I go about determining what ICD-10 codes support medical necessity for the IV...
  7. baroquecoder

    Recurring Periodic F/U visits for Resolved Conditions

    chief complaint; follow-up. Can a cardiologist continue to report a resolved I48.91 at every subsequent visit, complete with EKG of course, even though patient is asymptomatic? How about the extent to which they can report CAD I25.10 whereby the patient was treated and is asymptomatic now?
  8. baroquecoder

    Medical Necessity beyond purview.

    I am being told that validating E/M's to some extent is beyond my purview. Specifically medical necessity. I am being told that it is beyond my scope to recognize/question/or validate E/Ms with regard to their medical necessity. I am being told that we are to 'assume' that if the MD states in...
  9. baroquecoder

    Scheduled Follow Up with Pacemaker interrogation

    Patient seen every 4 months. Chief complaint exactly the same every time ; dual chamber pacemaker implant due to complete av block, 2003, Hypertension, Hyperlipidemia and Hypothyroidism. HPI: also the same copied and pasted from original history of pacemaker implant and continues as HPI with...
  10. baroquecoder

    Scheduled Follow Up with Pacemaker interrogation

    Oops this post is duplicated on the E/M forum. Please disregard.
  11. R

    LCD for Benign Skin Lesions

    I am wondering about how to code medical necessity for benign skin lesions for Medicare. LCD L34233 (Noridian) says the following: Medicare will consider the removal of benign skin lesions as medically necessary, and not cosmetic, if one or more of the following conditions is present and...
  12. D

    Medical Necessity Question

    Afternoon to all, I am new to the coding world and I'm currently coding for and Urgent Care with multiple facilities and Providers. Having an issue with one wanting to use Otalgia (ear pain) as medical necessity for 87880 Strep test. All my research and guidelines including the ones from the...
  13. A

    medical necessity

    Medical necessity is the overarching criterion in billing- I guess per Medicare, Medical Necessity is “Services or supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice.” I think this also have plenty of meanings-...
  14. C

    Chart Auditing-Compliance Commitee Otolaryngology

    I am interested is establishing a process/committee to audit Otolaryngology physician charts internally. We want to verify that medical necessity documentation is being met for procedures and that the documentation supports the CPT's billed. Has anyone set up an internal auditing process or...
  15. S

    Medical necessity in the hospice realm

    As a nurse auditor, I'm often presented with cases & claims for dates of service where it's pretty obvious that a recipient doesn't qualify for hospice services based on medical necessity. What we're having difficulty with is rephrasing that terminology so it can be adequately defended if we go...
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