2022 Gastroenterology Reimbursement and Coding Update: Concrete Solutions to Strengthen Your Foundation in GI Coding and Billing | November 2021-11 - Key to Economic Sucess Perfecting Proper Documentation Medical Necessity

11 - Key to Economic Sucess Perfecting Proper Documentation Medical Necessity_Mueller

Pdf Summary

The document titled "The Key to Economic Success: Perfecting Proper Documentation for Medical Necessity" is a presentation by Kathleen A Mueller, RN, CPC, CCS-P, CGCS, CMSCS, CCC, ICD-10 Proficient, from AskMueller Consulting, LLC. The objective of the presentation is to emphasize the importance of medical necessity for economic success in healthcare services. It explains that without medical necessity, services won't get preauthorization or payment, and there may be recoupment of previously paid services by payers. The top areas of payer focus for medical necessity are diagnostic EGD, infusion services, hemorrhoid treatment, multiple endoscopy, pathology and special stains, and evaluation and management services.<br /><br />The presentation provides guidelines for medical necessity for EGD (upper gastrointestinal endoscopy), including criteria for upper abdominal signs or symptoms, documented lesions, and various diagnostic purposes. It also discusses the importance of proper documentation for medical necessity for infusion services, such as lab studies, specific IBD condition, TB test results, and current medication orders.<br /><br />The document highlights the significance of evaluation and management (E&M) services in medical necessity and advises practices to review high-level visits for accuracy and educate providers on proper levels and diagnoses assignment. It mentions that diagnosis codes can trigger down-coding and emphasizes the role of documentation in justifying the level of service.<br /><br />The presentation also covers principles of medical record documentation, including completeness, legibility, inclusion of patient encounter details, healthcare risk factors identification, documentation of progress, and support for reported codes. It stresses the provider's role in assessment and plan documentation and advises against coding from a problem list.<br /><br />The document concludes with endoscopy billing tips, such as appropriate coding for polyp removal, EGD with biopsy, and other procedures. It also provides pearls of advice for medical necessity, including the specificity of documentation, timeliness of completion, staying updated on payer policies, and the justification of level of visit through medical decision making or time.<br /><br />Overall, this document offers valuable insights into the importance of proper documentation for medical necessity and provides guidelines for various aspects of healthcare services.

Keywords

economic success

proper documentation

medical necessity

healthcare services

preauthorization

payer focus

diagnostic EGD

infusion services

evaluation and management services

endoscopy billing tips