Medical necessity (CO 50) will be important denial if your DX is not matching with LCD policy. Know the basic of this denial to improve your medical billing

1. Denial Series

2. Medical Necessity
Definition:
Medical Treatment should be
1. In accordance with generally accepted standards of
medical practice
2. Clinically appropriate in terms of type, frequency,
extent, site and duration
3. Not primarily for the economic benefit of the
health plans and purchasers or for the convenience
of the patient, treating physician or other health
care provider.".

3. Information Required
 Patient name, ID#, age, gender
 Brief medical history
 Diagnosis, comorbidities, complications
 Signs and symptoms
 Progress of current treatment, including results
of pertinent testing
 Providers involved with care
 Proposed services
 Referring physician's expectations
 Psychosocial factors, home environment

4. Medical Records
Medical Records will contain the following information
1. Diagnosis – Condition of Illness
2. Treatment – Procedures done for the patient
3. Results of the Treatment
MR – Means of communication
MR – Legal Documents
All medical records must be complete, detailed, and
accurate. Any falsification of a patient medical record
will be grounds for immediate termination of
employment, civil action, and notification of the
appropriate state and/or federal agency!

5. Flow Chart
Pre call Analysis
.

6. Denials – Medical Records

7. ARMS – Screen Shot

9. PMS – Not Medical Necessity

10. PMS – Not Medical Necessity

11. Arms - NMN

15. Medical Policies
Empire BCBS
http://www.empireblue.com/medicalpolicies/search.html
Oxford
https://www.oxhp.com/secure/policy/clinical_policy_index_postpin.html
Aetna
http://www.aetna.com/healthcare-professionals/policies-
guidelines/medical_clinical_policy_bulletins.html
Cigna
http://www.cigna.com/customer_care/healthcare_professional/coverage_positions/index.
html
Medicare
http://www.cms.hhs.gov/mcd/search_advanced.asp?from2=search1%2Easp&
GE Healthcare Reimbursement policy - consolidated
http://www3.gehealthcare.com/en/Products/Reimbursement#tabs/tab8009EF37F1BD48D
380A1D0A4CF1F455C

16. Thank You