1. Coding for Medical Necessity
Chapter 10
Coding
for Medical Necessity

2. 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.

3. 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.

4. 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?

5. 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?

6. 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

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

8. 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.

9. 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.

10. 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

11. 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

12. 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

13. 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

14. 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

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

16. 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

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

18. 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

19. 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

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

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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

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

30. 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

31. 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

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