The criticality of medical necessity to coding

Medical necessity is often the difference between an allowed and a disallowed medical claim. This sums up the criticality of medical necessity. In the absence of a clearly mentioned cause of medical necessity, a claim is not likely to get approved. Why is this so? It is because a medical necessity is the decider in helping to determine why a certain medical service was needed. The most important rule for allowing medical claims is that there must have been a medical necessity for a procedure or treatment, and there should be no mismatch between the diagnosis and the procedure.

Often, coders make mistakes in not writing the right code. A wrongly entered code can be a reason for which a medical claim is denied. While mentioning the wrong diagnosis and treatment is a solid reason for the denial of a medical claim; the role of wrong coding is no less impactful. A patient may have come to have a broken rib sustained at an accident repaired, and the same accident may have also resulted in an elbow injury. When a wrong code for diagnosis is entered, then there is every chance that the claim for one of these injuries will get rejected.

The world of coding is quite complex. The ICD-10 has many complex codes, understanding of each of which in all its depth is absolutely necessary. Many a time, a coder could make an assumption about the diagnosis, the result of which is the wrong diagnosis code is entered. This may be a mistake on the part of the coder, but it is the responsivity of the patient to verify this, because the onus of ensuring this lies with the patient.

Learn more about how to get medical necessity coding right

A webinar that is being organized by MentorHealth, a leading provider of professional trainings for the healthcare industry, will offer valuable insights into how to avoid the costly errors of entering the wrong diagnosis code, which will go a long way in resulting in a claim denial.

At this webinar, Laura Hargraves, a senior professional in the field of healthcare, bringing about three decades of experience, will be the speaker. Interested in gaining sharper insights into the areas of medical necessity in coding? Then, please register for this webinar, by visiting

http://www.mentorhealth.com/control/w_product/~product_id=800949LIVE/?Wordpress-SEO

The OIG has been increasing its oversight

Of late, the Office of the Inspector General (OIG) has been carrying out audits with renewed vigor to determine if there has been any misuse of healthcare funding. Among the areas it has been focusing on are Hospitals, Skilled Nursing facilities and Home Health Care, where it wants to investigate if admissions and readmissions, and stay at such facilities for treatment were really warranted. It has found many cases of improper or unconvincing documentation of Medical Necessity. In such cases, Managed Care companies will deny coverage. A medical organization that does not show proper evidence in the form of documentation risks losing payment or reclamation of payment.

Documentation is the soul of medical necessity

At this webinar, Laura will offer show to participants how they can give the information they need for supporting their documentation efforts, which really is the heart of demonstration of medical necessity of services.

At this webinar, she will discuss an often overlooked area: The significance of the medical coding from Hospitalization to Home Care and the skilled nursing facility between. With the new coding guidelines for ICD-10 kicking in, knowing how to put documentation to the right use is of vital importance. This is because of the reason mentioned earlier, that of the need to match and document the services offered with the correct coding. Laura will give an understanding of how to do this important task.

Closer scrutiny

She will do this by looking at how the staff completes documentation, at the wording used, and what kind of supportive documentation is got from all departments. A close scrutiny of these items will help to understand and focus on the weak areas of documentation and continue to improve in areas that are functional but not optimal.

It is only when Medical Necessity is demonstrated that services are optimized. The way to reduce the risk of being denied claims is to ensure that departments’ documentation is supportive of the medical necessity of the services being provided.

At this webinar, Laura will cover the following areas:

• How is Medical Necessity Defined?
• Documentation needed to demonstrate Medical Necessity
• Rational behind documentation supporting coding
• Necessity for documentation to show progression of medical changes
• Interdepartmental documentation to show medical need for services.