Getting Medical Necessity Right

Getting Medical Necessity Right

Medical necessity is the single most important element in medical billing. Many times medical necessity comes down to the proper CPT code used for medical billing purposes.

It used to be that Medicare was the only payer that cared what ICD-9 code was used. Presently, all payers, including insurance companies, are looking for any reason not to pay the bill. ICD-9 codes have become the target.

ICD-9 codes range anywhere from a three-digit code to a five-digit code. Obviously, a five digit code is more descriptive then a four digit code. Similarly, a four digit code is more accurate then a three digit code. Very rarely will insurance companies pay a medical bill with a three-digit code anymore. Three digit codes don’t give all the medical billing information necessary to determine medical necessity. They are very generic codes. It is important when a medical biller decides to use an ICD-9 code, that is the most descriptive and accurate code available. Most of the time, this means a four or five digit code is in order.

Each and every year more ICD-9 codes are added to the list. Many medical practices are stretched to their limits and are unable to keep up with the changes. They end up resorting to generic three digit codes in their medical billing. When the payer gets the claim, they deny it for a lack of medical necessity and offer to review the case if a letter of medical necessity is sent. When this comes back to the practice, the office personnel must then put together a letter. This ends up stretching their time even thinner. It is a vicious cycle.

Medical billing firms can prevent this from happening. These firms make it their business to keep up with current medical billing practices and codes. Medical billing firms have revolutionized the medical industry by giving time back to medical practices.

View all Articles by: Melissa Clark, CCS-P