Healthcare Training Conferences - Establish Medical Necessity with CMS’ Documentation Guidelines

It is the responsibility of CMS to administer Medicare and other federally mandated healthcare programs throughout the United States. Medicare prohibits payment for services and items deemed by local Medicare Carriers as not medically reasonable and necessary for the diagnosis or treatment of an illness or injury, so here documentation is essential for claims to be paid.

There are a couple of points that a physician needs to ensure like only tests that are medically necessary in diagnosing or treating their patients should be asked for, correct ICD-9 codes to be used for patient files and test request forms, advance beneficiary notes to be signed by patients in case service gets denied.

Coders often overlook medical necessity in the evaluation and management (E/M) code assignment process. Medical necessity is a difficult concept for most coders to grasp and apply on a consistent basis in the E/M assignment process.

Definitions of medical necessity vary – depending on whom you are – physician, coder, biller, payer. Clear and to the point medical record documentation is critical to providing patients with quality care and is required in order for providers to receive accurate and timely payment for furnished services. It is also used to document all the care the patient receives and all the facts and findings related to him. Medical record documentation assists physicians and other health care professionals in evaluating and planning the patient’s immediate treatment and monitoring the patient’s health care over time.

Depending upon the type of history taken, extent of the physical exam performed, and the degree of decision-making required, specific office E/M codes are assigned by the coder. If the physician has overlooked any detail in the documentation of a past family and social history or ROS, the coder may seek clarification and documentation of these missing elements and proceed to assign a specific E/M code.

CMS Documentation Guidelines for providing medical necessity ensures that coders code correctly and the set of guidelines can be used for hospital training. Coders play an important role in educating physicians on the importance of documenting medical necessity that supports E/M code assignment for the services they perform. They also provide feedback to physicians to keep them updated of all the changes and avoid possible errors. Coders can also encourage physicians to bill when it is utterly important. The patient’s condition, severity, acuity, number of problems, etc., is critical in determining medical necessity for Medicare payment for services. The E/M code used must define the patient’s needs, work performed, and medical necessity. When an E/M service is coded with a high level based on the documentation of key component work, Medicare payment should not be asked for when the patient’s effective management does not require the code’s work. By adhering to these principles, physicians and coders can reduce potential financial reimbursement liabilities and allegations of over-documenting and upcoding.

If you are looking for online medical coding training conferences AudioEducator is the place where you can choose a wide range of medical coding conferences that includes topics on CMS’ Documentation Guidelines as well as helps you to train by providing conferences that covers topics like CMS hospital training guidelines and much more!