Coding for Medical Necessity

Review the following lecture:Coding for Medical NecessityCoding for Medical NecessityMedical necessity is a term that relates to whether a procedure or service provided to a patient was necessary to maintain or improve the state of health of the patient. Coding for medical necessity is required to assure a payer that the provided service or procedure was necessary.Medical practices in healthcare facilities routinely participate in an audit process that involves reviewing patient records and billing records to assess coding accuracy and completeness of documentation in the medical record. To facilitate these audits, CMS has provided the Medicare Coverage Database (MCD) that is used by the Medicare Administrative Contractors, providers, and other healthcare industry professionals to determine whether procedures or services are indeed reasonable and necessary for the diagnosis or treatment of an injury or illness. The MCD contains both the National Coverage Determinations (NCD) including draft policies and proposed decisions. The Local Coverage Determinations (LCD) includes policy articles. CMS maintains Medicare administrative contractors or Macs, which are the carriers that process claims in regions of the United States. In CDs link ICD-10-CM diagnosis codes with procedures and services that are considered reasonable and necessary for the diagnosis in the ICD code. The NCD may also indicate codes that will not be approved. The LCDs are additional information that may help providers for coding certain procedures with a diagnosis, but they do not override any NCD that may exist. LCDs are also only applicable within the region that created them. These medical necessity codes also apply to the institutional or hospital bills on the UB-04 also known as the CMS-1450 form.It is important to understand that these codes for medical are a necessity because the bills will not be paid if there are any issues with them.Medical Coverage DatabaseReview the following links to learn more about the medical coverage database.National and Local Coverage Determinations opens in new window Clarifications about NCDs and LCDs opens in new window Medicare LCDs and NCDs in Medical Coding and Billing opens in newwindow________________________________________From textbook, Understanding Health Insurance: A Guide to Billing and Reimbursement, review the following chapter:Coding for Medical NecessitIntroduction:In order to properly code a bill for medical necessity, it is important to understand the electronic medical record. This record contains information about the patient’s health both before and after the treatment and has the data needed to assure a payer that the treatment was necessary.Tasks:• Explain the contents of the medical record.• Describe SOAP notes—subjective, objective, assessment, and plan.• Explain operative reports function in medical necessity coding.• Explain National and Local coverage determinations.Submission Details:REQUREMENTS:5-10 page Essay with IN TEXT CITATIONS!!!!Includes all assignment components and meets graduate level critical thinking. A purpose statement is identified for the response.Paper shows ability to evaluate, apply and integrate key assignment concepts.Paper Synthesizes and justifies (defends, explains, validates, confirms) information gleaned from sources to support major points presented. Use APA7 format with 3 credible resources for the assignment, including at least 1 scholarly peer-reviewed resource.

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