Documentation Guidelines for different payors


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I have asked for this before and was directed to the AAPC Coding Edge article from Jan 2008. Which was great and helpful. Problem is the entity I am trying to inform thinks that AAPC standards are too high and unrealistic. I was actually told that "No physician in the country documents like that". I know for a fact this is not true because I have worked with many that do and did before they even came to the facilities I work/worked at. I am looking for spelled out guidelines on documentation requirements needed to prove medical necessity and involvement of PA's as assistant surgeons. I know the modifiers, I know the pay rates, and I know we have to submit documentation to prove medical necessity. What I am having difficulty finding is what constitutes medical necessity from a payor standpoint. I found it plainly spelled out for Alabama BC/BS, it was great! I am looking for that type of info from other payers to build up my case that the AAPC is not unrealistic in their assessment of what is required. Any help is greatly appreciated. I am located in Michigan but I am looking for any and all payors in all states if they have a clear cut policy.


Laura, CPC