Staying Current with Medical Necessity

A new quarter began on Oct. 1, an event that usually brings updates to National Coverage Determinations (NCDs). The coding updates included for Oct. 1 are specified in Change Request (CR) 13166, which is a maintenance update. This document is mentioned in the MLN Connects published Sept. 28.

Coding changes impacted NCD 20.20 (External Counterpulsation Therapy for Severe Angina); NCD 90.2 (Next Generation Sequencing), both effective Aug. 7; and NCD 210.1 (Prostate Screening Tests), effective Oct. 1.

It is important to know where to find these NCDs, and to be aware when they change, as these do affect medical necessity edits. Do you receive emails from the billing office when a case was not coded correctly, or a specific case failed medical necessity edits? Coders should review the medical record for additional diagnoses contained in the NCDs. If the case is outpatient, include the additional codes in the “Reason for Visit” fields. There are three available fields for Reason for Visit. You may want to verify that your abstracting system has been set up to accept three such diagnoses. If the case is inpatient, the diagnosis may be included as the admitting diagnosis or a secondary diagnosis.

Local Coverage Determinations (LCDs) are established by Medicare Administrative Contractors (MACs). The MACs have specific geographic areas, as seen in the map below:

LCD topics can vary among MACs. Their varying policies may be another reason why a case does not pass medical necessity. The LCDs are additional documents that may be reviewed for signs/symptoms/diagnoses that can be coded to remain compliant.

Coders can assist in recovering monies by reviewing cases that fail medical necessity edits. It is a best practice to review medical necessity prior to performing elective tests. When medical necessity is not met, physicians can be queried for additional signs and symptoms that led them to perform the test in question. If medical necessity is still not met, then the patient can be informed about the financial obligation and sign an Advanced Beneficiary Notice (ABN). This process should be completed prior to performing the test.

Many facilities write off cases that do not meet medical necessity, which reduces the facility’s financial status. The business office can produce a list of cases that did not pass medical necessity. This list can be worked daily by the coding staff, even after the cases have been completed. The coder will review the clinical documentation to determine if it supports additional diagnoses to be reported and passes medical necessity.

It is important in today’s environment to collect all the monies that are legitimately due to a facility. One place to start is reviewing cases that do not pass medical necessity.

Resources:

MLN Connects, September 28

NCD 90.2 “Next Generation Sequencing”: https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?NCDId=372

NCD 210.1 “Prostate Cancer Screening”: https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?NCDId=268

NCD 20.20 “External Counterpulsation Therapy for Severe Angina”: https://www.cms.gov/medicare-coverage-database/view/ncd.aspx?ncdid=97&ncdver=2

Medicare Administrative Contractors:  https://www.cms.gov/medicare/coding-billing/medicare-administrative-contractors-macs/who-are-macs#MapsandLists