Hospital policy vs Medicare Guidelines

Keitha L Scheib

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Can anyone guide me to CMS documentation that says something about a hospital policy that a medical doctor sees BHU patients daily versus Medicare stating we must bill only medically necessary visits regardless of hospital policy? Thanks
 

Keitha L Scheib

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Hospital policy vs medicare guidelines

if hospital policy dictates that a medical practitioner see BHU patients daily, that practitioner wants to bill each visit. But Medicare guidelines state that we only bill medically necessary visits. I need to prove that just going by and asking a patient how he's doing, he has no medical issues, but the practitioner is required to see them, we can't bill it.
 

mitchellde

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If I am reading this correctly, you have a patient in a behavioral health unit with psych diagnosis only. However your hospital policy is that a medical practitioner must see them every day even though there are no medical issues to address. If this is correct then you have no medical necessity to bill with which will make the medical visits non billable. Your medical provider should not use the behavioral diagnosis.
 

Keitha L Scheib

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Hospital policy vs medicare guidelines

Do you know a Medicare document that would state that? or any documentation for that point? I must be able to reinforce what I'm saying with documentation. I really appreciate any help I can get.
 

thomas7331

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As pertains to the E&M visits your concerned with, the usual reference for this is from the Medicare Claims Processing Manual, Chapter 12, see section 30.6.1, linked below: "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."

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

The source for this requirement is section 1862 of the SSA which excludes from Medicare payment those services that are not medically necessary:

https://www.ssa.gov/OP_Home/ssact/title18/1862.htm

Here's a good article that discusses medical necessity a little more and has references to sources of information:

http://www.aafp.org/fpm/2006/0700/p28.html

I recommend treading cautiously here, because saying that something is not medically necessary and saying that the documentation doesn't support medical necessity are two different things and it can become a touchy subject for providers. Clinical practitioners are really the ones who should make the final determination of what is medically necessary.
 
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