tci E/M Coding Alert - 2019 Issue Q3

Reader Question: Know How to Determine Medical Necessity

Question: My practice has had a couple of claims denied. The payers said the services rendered by our practice’s physician were not “medically necessary.” I’m sure the physician thought the services were medically necessary — otherwise he wouldn’t have ordered or performed them. What definitions are payers working from? Delaware Subscriber Answer: According to the American Medical Association’s (AMA’s) 2011 report to the Institute of Medicine’s Committee on Determination of Essential Health Benefits, the AMA defines medical necessity as “Health care services or products that a prudent physician would provide...

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