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Diagnosis not meet medical necessity

  1. Default Diagnosis not meet medical necessity
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    I have a concern for when Medicare patients come in and their diagnosis does meet medical necessity for a lab test. Our lab technicians are then trying to get a covered diagnosis. They will write as a query for example diagnosis needed to cover TSH per ________ fatigue and lethargic. Is this acceptable. How should we be handling these. Are there any resources or guidelines for this.

  2. #2
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    Columbia, MO
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    They need to accept that not every test will have a covered diagnosis. Also it is inappropriate if not rude to "suggest" to the physician what the diagnosis should be. We code for what the patient has as documented by the physician no more and no less, as I have stated many times we cannot give the patient a dx they do not have just to get a claim paid, as incorrect dx codes can cause harm to the patient.

    Debra A. Mitchell, MSPH, CPC-H

  3. Default
    I completely agree with you and feel it is upcoding that will be viewed by Medicare.
    so how can I get them to stop? I need supporting documentation.

  4. #4
    Location
    Columbia, MO
    Posts
    12,570
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    It is not so much upcoding as it is misrepresentation of the encounter. That then constitutes a false claim and comes under the false claims act. If you start looking you will find many different violations you can come up with. Not to mention what the patient could do if/when they find out they have been tagged with a diagnosis they do not have.

    Debra A. Mitchell, MSPH, CPC-H

  5. #5
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    i would contact the office thats ordering the tests and let them know of the LCD. if the patient doesnt carry one of the supporting diagnosis on the LCD, the office needs to get an ABN signed.
    Dawnelle Beall, CPC, CPMA, CPC-I
    Licensed AAPC PMCC Instructor
    AAPC ICD-10CM Certified Trainer
    Previous AAPC Local Chapter President & VP

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