tci General Surgery Coding Alert - 2019 Issue Q4

Reader Question: Focus ‘Medical Necessity’ for Billing

Question: Sometimes we get denials for a procedure our surgeon performed due to lack of “medical necessity.” What exactly does that mean, and how can we avoid this type of denial in the future? SuperCoder Subscriber Answer: The AMA defines medical necessity as “healthcare services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease, or its symptoms in a manner that is: (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate in terms of type, frequency, extent, site...

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