2024 Gastroenterology Reimbursement and Coding Update (Virtual) | November 2023-13 - The Key to Economic Success Medical Necessity

13 - The Key to Economic Success Medical Necessity_Mueller

Pdf Summary

The document highlights the importance of proper documentation for medical necessity in order to achieve economic success in healthcare. Without medical necessity, services may not get preauthorization or payment, and payers may seek recoupment of previously paid services. The focus areas for payers regarding medical necessity include diagnostic EGD, infusion services, hemorrhoid treatment, multiple endoscopy, pathology and special stains, and screening versus diagnostic colonoscopy. Proper documentation is crucial for evaluation and management services (E&M) as well. Diagnosis codes can trigger down-coding of service levels, and multiple down-coded claims can lead to audits. Providers need to pay attention to the core elements of E&M services and ensure that diagnosis codes align with the patient's chief complaint, history, physical examination, and impression/plan of care. The document also emphasizes the principles of medical record documentation, such as completeness, legibility, documenting the reason for the encounter, assessment, plan for care, and supporting CPT and ICD-10 codes. The provider's role in assessment and plan is discussed, emphasizing the need for clear assessment, specific diagnoses, and evaluation and treatment for each condition related to an ICD-10 code. The document also provides billing tips for endoscopy procedures, including considerations for EGDs and different techniques for various lesions. Medical necessity pearls are shared, such as listing specific symptoms, comorbidities, and risk factors, completing documentation in a timely manner, staying up-to-date on payer policies, and justifying the level of visit based on medical decision making or time. Overall, the document stresses the significance of proper documentation for medical necessity to achieve economic success in healthcare.

Keywords

proper documentation

medical necessity

economic success

preauthorization

diagnostic EGD

evaluation and management services

diagnosis codes

medical record documentation

billing tips

medical decision making