Wiki Medical necessity

[WFassnacht]

We are having a debate on medical necessity with a patient encounter. We are being instructed to not determine medical necessity but only to bill what the doctor documents. We have been trained that medical necessity is essential for every service provided for a patient.

thanks

 

[mitchellde]

I am not understanding your question. Unless the provider documents the medical necessity, the coder will not be able to determine what it is. Can you provide an example of what you are talking about?

 

[WFassnacht]

i have a patient that is in a global period for a femur fx fixation that was performed by a different provider in Ortho. My provider has gone in the next day after orhto saw the patient eariler in the day & the only dx on my note listed by provider is the same as the dx the ortho did the surgery for. there is nothing else my provider is looking at.
thanks

 

[mitchellde]

Then you use the fracture code with subsequent 7th character. If your provider is also Ortho and you are in the same group then it will be considered global. If your provider is not Ortho and yet did not document the reason for the visit with the patient then you will still use the fracture code with subsequent, the problem is most carriers will deny as part of another providers global. There is nothing a coder can do with poor documentation.