Coding for Medical Necessity Chapter 10 Coding for Medical Necessity

Coding for Medical Necessity The next step in learning to code correctly is to choose diagnoses and procedures/services from a case and link each procedure/service.

Coding for Medical Necessity This chapter requires you to review case scenarios and patient reports to decide the right diagnoses and procedures/services to be coded, and medical necessity issues.

Questions for Consideration Does this diagnosis or condition support a procedure or service provided during this encounter? Did the provider prescribe a new medication or change a prescription for a new or existing diagnosis or condition?

Questions for Consideration Are positive diagnostic test results documented in the patient record to support a diagnosis or condition? Did the provider have to consider the impact of treatment for chronic conditions when treating a newly diagnosed condition?

Coding and Billing Considerations You should also incorporate the following as part of practice management Completion of an Advance Beneficiary Notice (ABN) when appropriate Implementation of an auditing process

Coding and Billing Considerations Review of local coverage determinations Complete and timely patient record documentation Use of Outpatient Code Editor (OCE) Software

Coding and Billing Considerations The following characteristics are associated with patient record documentation in all health care settings. Documentation should be generated at the time of service or shortly thereafter.

Coding and Billing Considerations Delayed entries within a practical time frame (24 to 48 hours) are acceptable for purposes of clarification, corrections of errors, addition of information not initially available.

Coding and Billing Considerations The patient record cannot be altered: Corrections or additions to the patient record must be dated, timed, and legibly signed or initialed Patient record entries must be legible Entries should be dated, timed, and authenticated by the author

Coding and Billing Considerations Medical practices and health care facilities should regularly participate in an auditing process Allows for review of patient records and CMS-1500 or UB-92 claims to evaluate coding accuracy and completeness of documentation

Coding and Billing Considerations Local coverage determinations specify under what clinical circumstances a service is covered and correctly coded OCE Software that edits outpatient claims submitted by hospitals, home health agencies, and other facilities

Coding from Case Scenarios Case scenarios are a summary of medical dates from patients’ records Introduces students to the process of abstracting diagnoses and procedures

Coding from Case Scenarios Step 1 Read case scenario and look up any words you don’t understand Step 2 Reread Highlight diagnoses and symptoms Those that support medical necessity of the procedures performed

Coding from Case Scenarios Step 3 Code documented diagnoses, symptoms, procedures, signs, health status, and services Step 4 Assign any modifiers that are appropriate

Coding from Case Scenarios Step 5: Identify primary condition Step 6: Link any procedure or services that were provided to the diagnosis to show medical necessity

Coding from Patient Reports Services, diagnoses, and procedures Chosen and coded from the clinic notes, diagnostic reports, and the consultation reports

Secondary Purposes Patient records do not relate directly to patient care, and they include: Evaluating quality of patient care Providing information to third-party payers for reimbursement Providing data for use in education, clinical research, and other uses

Clinic Notes There are two major formats that health care providers use for documenting clinic notes: Narrative clinic notes SOAP notes Written in paragraph format

SOAP Notes Written in outline format SOAP: Subjective Objective Assessment Plan

SOAP Notes Subjective Objective Part that contains the chief complaint Contains documentation of measurable observations made during the physical examination and diagnostic testing

SOAP Notes Assessment Plan Contains diagnostic statement and may also include physician rationale behind diagnosis Plan Statement for physician’s plans for work-up and medical management of the case

Operative Reports Narrative of minor procedures that may have been performed in a physician’s office, to a more formal report by the surgeon Required by hospitals and ambulatory surgical centers

Information Contained in Outline Forms Date of surgery Patient identification Pre- and postoperative diagnosis(es) List of the procedure(s) performed Name of primary and secondary surgeons who performed surgery

The Body of the Report Positioning and draping of patient for surgery Achievement of anesthesia Detailed description of how the procedure(s) were performed Identification of abnormalities found during the surgery

The Body of the Report Description of how homeostasis was obtained and closure of surgical site(s) Condition of patient when they left the operating room Signature of surgeon

Procedure for Coding Operative Reports Step 1 Make a copy of report Step 2 Carefully review all procedures performed Step 3 Read body of report and make notes of procedures that need to be coded

Procedure for Coding Operative Reports Step 4 Identify main terms and subterms for procedures to be coded Step 5 Underline and research any terms in the report that you cannot define

Procedure for Coding Operative Reports Step 6 Locate main terms in CPT/ index Step 7 Research all the suggested codes

Procedure for Coding Operative Reports Step 8 Return to index if you cannot find a code that matches the description of the procedures performed Step 9 See if there are any modifiers that need to go on the procedures to explain it fully

Procedure for Coding Operative Reports Step 10 Code postoperative diagnosis Step 11 Review code options with the physician Step 12 Assign final codes and any addendum the physician added to the original report

Procedure for Coding Operative Reports Step 13 List most significant procedure performed first Step 14 Be sure to destroy your copy of the report