copyright © 2008 delmar learning. all rights reserved. chapter 10 coding for medical necessity

Copyright © 2008 Delmar Learning. All rights reserved.

Chapter 10

Coding

for Medical Necessity


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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.


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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.


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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?


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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?


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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


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• Review of local coverage determinations

• Complete and timely patient record documentation

• Use of Outpatient Code Editor (OCE) Software


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• 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.


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• 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.


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• 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


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• 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


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Codingand 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


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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


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• 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


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• Step 3– Code documented diagnoses, symptoms,

procedures, signs, health status, and services

• Step 4– Assign any modifiers that are appropriate


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• Step 5: – Identify primary condition

• Step 6: – Link any procedure or services that were

provided to the diagnosis to show medical necessity


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Coding from Patient Reports

• Services, diagnoses, and procedures– Chosen and coded from the clinic notes,

diagnostic reports, and the consultation reports


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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


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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


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SOAP Notes

• Written in outline format

• SOAP:– Subjective– Objective– Assessment – Plan


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SOAP Notes

• Subjective – Part that contains the chief complaint

• Objective – Contains documentation of measurable

observations made during the physical examination and diagnostic testing


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SOAP Notes

• Assessment – 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


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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


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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


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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


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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


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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


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• 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


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Procedure forCoding Operative Reports

• Step 6 – Locate main terms in CPT/ index

• Step 7 – Research all the suggested codes


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Procedure forCoding 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


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• 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


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• Step 13 – List most significant procedure performed first

• Step 14 – Be sure to destroy your copy of the report

copyright © 2008 delmar learning. all rights reserved. chapter 10 coding for medical necessity

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