tci Medicare Compliance & Reimbursement - 2008 Issue 1

Reader Question: Consider Redetermination To Prove Medical Necessity

Tip: Check the LCD list before you appeal Question: We performed a service that we know was medically necessary, but the carrier denied it. Is redetermination the only way to proceed with trying to get this claim paid, or is there another way to get Medicare to reconsider? Answer: Your Medicare carrier is probably determining that it is "medically unnecessary" because of one of two reasons, says Barbara Cobuzzi, MBA, CPC, CPC-H, CPC-P, CPC-OT, CHCC, director of outreach for the American Academy of Professional Coders in Salt Lake City. "One, it exceeds frequency limits (believe it or not, you...

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