Medical necessity refers to the requirement that a healthcare service or procedure must be reasonable and necessary to diagnose or treat a patient’s medical condition

QUESTION

AH1006 Performance Evaluation Checklist 2

MAERB Cognitive Competency:

IX.C.5 Define medical necessity as it applies to procedural and diagnostic coding (BL2)

MAERB Psychomotor Competency:

IX.P.1 Perform procedural coding (BL2)

IX.P.3 Utilize medical necessity guidelines (BL3)

Objectives:    

• Identify linkage between diagnosis and procedure codes in relation to medical necessity
• Apply medical necessity guidelines to real life scenarios in order to ensure accuracy in coding
• Apply knowledge of coding principles by assigning accurate and precise outpatient procedure codes

Task:  Read the following scenario and apply knowledge of coding principles to assign accurate and precise procedure codes, utilizing medical necessity guidelines.

Standards:    Perform this objective within 60 minutes with a minimum score of 74.

PART I: Define medical necessity as it relates to diagnostic and procedural coding.

(Answers must be written in complete sentences).

PART II: Read the following scenario and answer the questions that follow, using the CPT Manual and your knowledge of medical necessity guidelines.

On 5/15/2023, patient, Jason Jones visited his surgeon, Dr. Mariah Keith. The patient had been experiencing occasional rectal bleeding. The surgeon performed a colonoscopy that extended to the cecum. A biopsy was taken of tissue from the ascending colon. The source of the bleeding was not found. At this visit, the patient also complained of lower back pain and the surgeon ordered a lower back x-ray. The x-ray was done at this same visit. The diagnosis submitted for the visit was rectal bleeding, ____K62.5_____.

A)        Assign CPT codes for all procedures performed during this encounter. (30 Points)

B)       Utilizing medical necessity guidelines, discuss any issues with the linkage between diagnosis and procedure codes submitted for this encounter.   Will the provider be reimbursed for all procedures?  Why/why not?  Please be specific in your response, using complete, well structured sentences.

ANSWER

Part I: Medical Necessity in Diagnostic and Procedural Coding

Medical necessity refers to the requirement that a healthcare service or procedure must be reasonable and necessary to diagnose or treat a patient’s medical condition. It ensures that services provided are appropriate for the patient’s symptoms, diagnosis, and overall health status. In diagnostic and procedural coding, medical necessity is crucial as it justifies the need for specific tests, treatments, or interventions based on the patient’s clinical condition. Proper coding with consideration of medical necessity ensures that healthcare providers receive appropriate reimbursement for the services rendered.

Part II: Coding Scenario and Medical Necessity Guidelines

CPT Codes for Procedures Performed

Colonoscopy with biopsy: CPT code 45380 – Colonoscopy, flexible; with biopsy.
Lower back x-ray: CPT code 72100 – X-ray, lumbosacral spine, 2 or 3 views.

Discussion of Medical Necessity and Reimbursement

In this encounter, the patient presented with rectal bleeding, and the surgeon performed a colonoscopy with a biopsy to identify the source of bleeding. Additionally, the patient complained of lower back pain, and the surgeon ordered a lower back x-ray.

For the colonoscopy with biopsy, the CPT code 45380 accurately represents the procedure performed. However, to ensure proper reimbursement, it is essential to establish medical necessity. The submitted diagnosis of “rectal bleeding” (ICD-10 code K62.5) supports the need for the colonoscopy as a diagnostic tool to identify the source of the bleeding. The linkage between the diagnosis and procedure code is appropriate, and the provider is likely to receive reimbursement for this service.

Regarding the lower back x-ray, the CPT code 72100 accurately represents the procedure performed. However, the linkage between the diagnosis and procedure codes may pose an issue with medical necessity. The diagnosis of “rectal bleeding” is not directly related to the need for a lower back x-ray. To ensure reimbursement, the surgeon must provide documentation justifying the medical necessity of the x-ray in relation to the patient’s lower back pain. If sufficient evidence of medical necessity is not provided, the provider may face challenges in receiving reimbursement for the lower back x-ray.

In conclusion, appropriate coding with consideration of medical necessity is crucial for ensuring accurate reimbursement for healthcare services. The provider should ensure that the documentation supports the linkage between the diagnosis and procedures to justify the medical necessity of each service provided during the encounter. This not only ensures proper reimbursement but also promotes quality patient care and compliance with coding guidelines.