BC Advantage - 2018 Issue 8

When Medical Necessity and Medical Decision Making Don't Match

As coders and auditors, we are taught the documentation guidelines on how to determine medical decision making. However, Medicare is clear that medical necessity is what determines the overall payment. In order to know what to do when medical necessity and medical decision making do not line up, you must first look at how they are determined. Determining Medical Necessity (MN)Although there are great tools and resources to determine MDM, the documentation guidelines do not illuminate how to capture this elusive, yet critical element, for supporting the level of service. There are caveats, and exclusions, but nothing that...

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