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Medical Necessity

  1. #1
    Default Medical Necessity
    Medical Coding Books
    Commercial insurance audit activity in my area has prompted some worried questions from a few of my providers. Although we are very clear on benign lesion removal policies with respect to medical necessity, one commercial carrier may be toughening up on supporting the medical necessity of skin biopsies. "Suspected malignancy" is a common term I see in policies, but I'm hoping some of you would share some of the descriptions you typically see in your provider's documentation that seem to support the medical necessity of performing a biopsy. For instance, if you see a provider's description of a lesion as "red lesion that crusts, heals, and crusts again" would that be enough or do your providers typically add more robust descriptions that include statements about pearly telangiectic papules that bleed and crust? (I'm thinking r/o bcc here.) Of course our providers don't add in descriptions they don't find on exam, but I think we all know that sometimes they provide bare minimum details, especially on those days when they have too many add-ons on their schedules. Thanks in advance for sharing your thoughts.

  2. #2
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    Quote Originally Posted by khanninen View Post
    Commercial insurance audit activity in my area has prompted some worried questions from a few of my providers. Although we are very clear on benign lesion removal policies with respect to medical necessity, one commercial carrier may be toughening up on supporting the medical necessity of skin biopsies. "Suspected malignancy" is a common term I see in policies, but I'm hoping some of you would share some of the descriptions you typically see in your provider's documentation that seem to support the medical necessity of performing a biopsy. For instance, if you see a provider's description of a lesion as "red lesion that crusts, heals, and crusts again" would that be enough or do your providers typically add more robust descriptions that include statements about pearly telangiectic papules that bleed and crust? (I'm thinking r/o bcc here.) Of course our providers don't add in descriptions they don't find on exam, but I think we all know that sometimes they provide bare minimum details, especially on those days when they have too many add-ons on their schedules. Thanks in advance for sharing your thoughts.
    It's up to the doctor's discretion, as to whether or not they believe that there's a chance of malignancy. Many payers will consider lesion removal medically necessary if it interefere's with their daily living activities, or poses a risk for further injury (eg, a skin tag that gets caught on clothing) - if it's bleeding, then there's a chance it could be covered anyways. Just tell them to document well, and to advise the patient when they think it will be deemed 'cosmetic', before removing it.

  3. #3
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    Columbia, MO
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    if documentation supports suspicion of malignancy but the path report shows only benign then you can use V71.1 for your medical necessity.

    Debra A. Mitchell, MSPH, CPC-H

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