2023 Gastroenterology Reimbursement and Coding Update (On-Demand) | November 2022-Key to Economic Success Perfecting Proper Documentation for Medical Necessity

Pdf Summary

The document discusses the importance of proper documentation for medical necessity in order to achieve economic success. Without medical necessity, services won't get preauthorization or payment, and payers may seek recoupment of previously paid services. The document highlights key areas of payer focus for medical necessity, including diagnostic EGD, infusion services, hemorrhoid treatment, multiple endoscopy, pathology and special stains, and screening versus diagnostic colonoscopy.<br /><br />For diagnostic EGD, the document advises ensuring specific documentation in the patient's medical record, including pertinent history, PCP's record, labs, radiology studies, and patient symptoms.<br /><br />The document provides criteria for medical necessity for EGD, upper abdominal signs or symptoms, and when EGD is not medically necessary. Similarly, it advises proper documentation for infusion services, including reasons for the initiation/change of biologic agent, specific IBD condition, TB test and vaccination status, and medication order.<br /><br />The importance of proper documentation for evaluation and management (E&M) services is highlighted. The document advises basing the level of visits on decision making or time and monitoring high-level visits before claim submission. It warns that diagnosis codes can trigger down-coding and emphasizes the role of medical decision making for establishing E&M service levels.<br /><br />General principles of medical record documentation are provided, including completeness, legibility, inclusion of reason for encounter, assessment, plan for care, and supporting diagnostic and ancillary service orders.<br /><br />The document emphasizes the need for accurate and specific documentation to support medical necessity and proper coding. It provides examples of specific documentation and coding for various conditions and procedures.<br /><br />Finally, the document provides tips for proper documentation and coding for endoscopic procedures, including the avoidance of bundled codes, use of modifiers, and specifying locations and methods. It emphasizes the importance of listing symptoms, indications, and comorbidities, as well as completing and signing documents on time.<br /><br />Overall, the document emphasizes the importance of proper documentation for medical necessity to ensure preauthorization, payment, and compliance with payer policies. It provides specific criteria and examples for different procedures and conditions.

Asset Subtitle

Kathleen A. Mueller, RN, CPC, QMC, QGMC, CCS-P, ICD-10 Proficient

Keywords

medical necessity

proper documentation

preauthorization

payment

diagnostic EGD

infusion services

evaluation and management services

down-coding

completeness

endoscopic procedures