Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
© Copyright 2007 American Health Information Management Association. All rights reserved.
Disclaimer
To earn one (1) continuing education unit, each participant must do the following:
Step 1: Listen to the seminar, via Webcast link, audio CD, or MP3.
Step 4: After you complete the evaluation, you will receive your CE certificate which
you should print for your records. The certificate must be retained by each
participant as a record of their participation, along with a copy of their completed
quiz.
i
Faculty
Dianne Wilkinson, RHIT
Dianne Wilkinson is in her 38th year working in healthcare. The first 25 were in the
hospital setting, working in medical records, quality assurance, JCAHO coordination,
risk management, and utilization management. She earned her RHIT credential in
1980, her CPHQ (Certified Professional in Healthcare Quality) in 1988, and her CCP
(Credentialed Compliance Professional) in 2004. In 1995 she was recruited to the
physician office setting in her current position, Quality Manager/Compliance Officer for
MedSouth Healthcare in Dyersburg, Tennessee.
Ms. Wilkinson performs consulting services for physician clients in West and Middle
Tennessee who outsource their compliance activities, especially the education and
auditing/monitoring components. Ms. Wilkinson says she still passionately loves what
she does for a living, just as she did when she began working in the healthcare field in
1969.
ii
Table of Contents
Disclaimer ..................................................................................................................... i
How to earn one (1) CEU for participation ......................................................................... i
Faculty .........................................................................................................................ii
Medical Necessity and Medicare: Some Facts................................................................... 1
Local Coverage Decisions (LCDs) ..................................................................................... 2
National Coverage Decisions (NCDs) ................................................................................ 2
What do LCDs and NCDs Mean to the Physician Practice: .................................................. 3
Challenges for Physicians Associated with Medicare Rules for LCDs/NCDs ........................... 3
Medical Necessity: Best Practices in Coding and Billing .................................................. 4-6
Medical Necessity: Best Practices in Documentation ...................................................... 6-8
Resource/Reference List ................................................................................................. 8
Helpful CMS Resources on Medical Necessity ........................................................ 9
AHIMA Audio Seminars ................................................................................................... 9
About assessment quiz ..................................................................................................10
Thank you for attending (with link for evaluation survey) .................................................10
Appendix ..................................................................................................................11
Resource List .......................................................................................................12
Attachments ........................................................................................................13
“Reasonable and Necessary” section of the OIG Final Compliance Program,
Guidance for Individual and Small Group Physician Practices
Notice of Exclusions from Medicare Benefits (NEMB)
Advance Beneficiary Notice
Assessment Quiz
CE Certificate and Sign-in Instructions
Quiz Answer Key
Medical Necessity Notes/Comments
1
Medical Necessity Notes/Comments
2
Medical Necessity Notes/Comments
• That many tests and procedures they want to order have coverage
restrictions by Medicare.
• That if the physician just re-located from New York to Tennessee, he
will not necessarily find the same tests and procedures that have
restricted coverage in both States.
• A Medicare carrier’s list of current LCDs can change often; individual
LCDs can be revised often; LCDs can be declared inactive, but for
practical purposes should still be followed!
• Failure to stay current with your carrier’s LCDs puts you at risk for
lost reimbursement; because if you receive a denial from Medicare
due to medical necessity which cannot be appealed, and you have
not obtained an Advance Beneficiary Notice (ABN) from your patient,
your only option is a write-off.
• If a physician Practice is writing off large amounts due to medical
necessity denials from Medicare, the patients are not paying for
these services; this perpetuates a common “myth” among Medicare
patients… that Medicare covers “everything”.
5
• Since not all tests and procedures have limited Medicare coverage,
the burden is on physicians to know on any given day which ones do
(and are pertinent to their Practice) for their particular Medicare
carrier.
• This involves the physician, or a nurse or other staff person, checking
the carrier’s web site for current LCDs (and Lab staff staying abreast
of current NCDs and keeping physicians informed). In a significant
number of physician Practices, physicians are not staying current
with their State’s LCDs. This will most certainly result in Medicare
denials for medical necessity.
• Reviewing LCDs and obtaining the Advance Beneficiary Notice if
needed must be done prior to rendering the service. Most physicians
are not focusing on billing issues at the beginning of a patient
encounter. At the end of the encounter, it’s too late.
• LCDs and NCDs are often revised; LCDs can be rendered inactive;
new LCDs are published. Someone in the Practice needs to stay
current with all this information from Medicare carriers and publish it
to all physicians and pertinent staff. In my experience, this is not
done as consistently as it should be.
6
3
Medical Necessity Notes/Comments
Medical Necessity:
Best Practices in Coding and Billing
Medical Necessity:
Best Practices in Coding and Billing (Continued)
Continued…
8
4
Medical Necessity Notes/Comments
Medical Necessity:
Best Practices in Coding and Billing (Continued)
Medical Necessity:
Best Practices in Coding and Billing (Continued)
5
Medical Necessity Notes/Comments
Medical Necessity:
Best Practices in Coding and Billing (Continued)
Do all the clinical work necessary for the patient, based on the
nature of presenting problem(s); document history, exam, and
decision-making based on what was necessary to work up and/or
treat the patient’s problem(s). Include all tests and procedures
performed or ordered. Then code and bill from what was
documented, assuring that the superbill is an accurate reflection of
the chart note, and that all codes are accurate, appropriate modifiers
are used, and that every test/procedure on the claim is linked to the
appropriate diagnosis code that establishes medical necessity.
11
Medical Necessity:
Best Practices in Documentation
6
Medical Necessity Notes/Comments
Medical Necessity:
Best Practices in Documentation (Continued)
Medical Necessity:
Best Practices in Documentation (Continued)
7
Medical Necessity Notes/Comments
Medical Necessity:
Best Practices in Documentation (Continued)
15
Resource/Reference List
Book
• AHIMA Publication: Health Information Management Compliance: Guidelines
for Preventing Fraud and Abuse, Fourth Edition; by Sue Bowman.
https://imis.ahima.org//orders/productDetail.cfm?pc=AB102107
Articles
• “Reasonable and Necessary” section of the OIG Final Compliance Program
Guidance for Individual and Small Group Physician Practices (October 5,
2000; FR page 59439): www.oig.hhs.gov/fraud/complianceguidance.html
• "Comprehensive Error Rate Testing (CERT) Report," article from July, 2007
"Medicare Bulletin: Tennessee" by Cigna Government Services, regarding
medical necessity of evaluation and management (E&M) services (pg. 1):
www.cignamedicare.com/partb/pubs/mb/2007/07_07/PDFs/TN_07_07.pdf
• “Medical Record Cloning, ”article from March/April, 1999 "Medicare Bulletin:
Tennessee" by Cigna Government Services (pg. 12):
www.cignamedicare.com/partb/pubs/mb/1999/99_2/PDFs/b992tn.pdf
• “Phantom Double Plays, Histories and Physicals," article from December,
2001 "Medicare Bulletin" from Wisconsin Physicians Service (pp. 2-3):
www.wpsmedicare.com/provider/pdfs/1201bltn.pdf
16
8
Medical Necessity Notes/Comments
• Notice of Exclusions from Medicare Benefits (NEMB), which lists services that
are statutorily non-covered, and therefore would never be considered
“medically necessary” for Medicare payment (these services should be the
patient’s responsibility to pay)
www.cms.hhs.gov/BNI/Downloads/CMS20007English.pdf
• Example of a dedicated Advance Beneficiary Notice (ABN).
Form Number: CMS R 131-G
www.cms.hhs.gov/cmsforms/downloads/cmsr-131-g.pdf
9
Medical Necessity Notes/Comments
Assessment
http://campus.ahima.org/audio/fastfactsresources.html
http://campus.ahima.org/audio/fastfactsresources.html
10
Appendix
Resource List
Attachments
“Reasonable and Necessary” section of the OIG Final Compliance Program, Guidance for
Individual and Small Group Physician Practices
Notice of Exclusions from Medicare Benefits (NEMB)
Advance Beneficiary Notice
Assessment Quiz
CE Certificate and Sign-in Instructions
Quiz Answer Key
Appendix
Resource List
Attachments
“Reasonable and Necessary” section of the OIG Final Compliance Program, Guidance for Individual and Small
Group Physician Practices (October 5, 2000; Federal Register pages 59439-40)
http://www.oig.hhs.gov/fraud/complianceguidance.html
Notice of Exclusions from Medicare Benefits (NEMB); Form No. CMS-20007 (January 2003)
Book
AHIMA Publication: Health Information Management Compliance: Guidelines for Preventing Fraud and Abuse,
Fourth Edition; by Sue Bowman.
https://imis.ahima.org//orders/productDetail.cfm?pc=AB102107
Articles
“Reasonable and Necessary” section of the OIG Final Compliance Program Guidance for Individual and Small
Group Physician Practices (October 5, 2000; FR page 59439)
http://www.oig.hhs.gov/fraud/complianceguidance.html
"Comprehensive Error Rate Testing (CERT) Report," article from July, 2007 "Medicare Bulletin: Tennessee" by
Cigna Government Services, regarding medical necessity of evaluation and management (E&M) services (pg. 1)
http://www.cignamedicare.com/partb/pubs/mb/2007/07_07/PDFs/TN_07_07.pdf
“Medical Record Cloning,” article from March/April, 1999 "Medicare Bulletin: Tennessee" by Cigna Government
Services (pg. 12)
http://www.cignamedicare.com/partb/pubs/mb/1999/99_2/PDFs/b992tn.pdf
“Phantom Double Plays, Histories and Physicals," article from December, 2001 "Medicare Bulletin" from
Wisconsin Physicians Service (pp. 2-3)
http://www.wpsmedicare.com/provider/pdfs/1201bltn.pdf
CMS
Medicare’s Notice of Exclusions from Medicare Benefits (NEMB), which lists services that are statutorily non-
covered, and therefore would never be considered “medically necessary” for Medicare payment
(These services should be the patient’s responsibility to pay)
http://www.cms.hhs.gov/BNI/Downloads/CMS20007English.pdf
Example of a dedicated Advance Beneficiary Notice (ABN). Form Number: CMS R 131-G
http://www.cms.hhs.gov/cmsforms/downloads/cmsr-131-g.pdf
Office of Inspector General's Compliance Program Guidance for Individual and Small
Group Physician Practices: II(B) Step 2 (1)(b)
Footnote:
23 ‘‘* * * for the diagnosis or treatment of illness or injury or to improve the functioning
of a malformed body member.’’ 42 U.S.C. 1395y(a)(1)(A).
Excerpt from: Federal Register / Vol. 65, No. 194 / Thursday, October 5, 2000 / Notices
NOTICE OF EXCLUSIONS FROM MEDICARE BENEFITS (NEMB)
There are items and services for which Medicare will not pay.
• Medicare does not pay for all of your health care costs. Medicare only pays for covered benefits.
Some items and services are not Medicare benefits and Medicare will not pay for them.
• When you receive an item or service that is not a Medicare benefit, you are responsible to pay for it,
personally or through any other insurance that you may have.
The purpose of this notice is to help you make an informed choice about whether or not
you want to receive these items or services, knowing that you will have to pay for them yourself.
Before you make a decision, you should read this entire notice carefully.
Ask us to explain, if you don’t understand why Medicare won’t pay.
Ask us how much these items or services will cost you (Estimated Cost: $_____________).
□ Personal comfort items. □ Routine physicals and most tests for screening.
□ Most shots (vaccinations). □ Routine eye care, eyeglasses and examinations.
□ Hearing aids and hearing examinations. □ Cosmetic surgery.
□ Most outpatient prescription drugs. □ Dental care and dentures (in most cases).
□ Orthopedic shoes and foot supports (orthotics). □ Routine foot care and flat foot care.
□ Health care received outside of the USA. □ Services by immediate relatives.
□ Services required as a result of war. □ Services under a physician’s private contract.
□ Services paid for by a governmental entity that is not Medicare.
□ Services for which the patient has no legal obligation to pay.
□ Home health services furnished under a plan of care, if the agency does not submit the claim.
□ Items and services excluded under the Assisted Suicide Funding Restriction Act of 1997.
□ Items or services furnished in a competitive acquisition area by any entity that does not have a contract
with the Department of Health and Human Services (except in a case of urgent need).
□ Physicians’ services performed by a physician assistant, midwife, psychologist, or nurse anesthetist,
when furnished to an inpatient, unless they are furnished under arrangements by the hospital.
□ Items and services furnished to an individual who is a resident of a skilled nursing facility (a SNF)
or of a part of a facility that includes a SNF, unless they are furnished under arrangements by the SNF.
□ Services of an assistant at surgery without prior approval from the peer review organization.
□ Outpatient occupational and physical therapy services furnished incident to a physician’s services.
* This is only a general summary of exclusions from Medicare benefits. It is not a legal document.
The official Medicare program provisions are contained in relevant laws, regulations, and rulings.
Because:
The purpose of this form is to help you make an informed choice about whether or not you
want to receive these items or services, knowing that you might have to pay for them yourself.
Before you make a decision about your options, you should read this entire notice carefully.
• Ask us to explain, if you don’t understand why Medicare probably won’t pay.
• Ask us how much these items or services will cost you (Estimated Cost: $_________________),
in case you have to pay for them yourself or through other insurance.
PLEASE CHOOSE ONE OPTION. CHECK ONE BOX. SIGN & DATE YOUR CHOICE.
Option 1. YES. I want to receive these items or services.
I understand that Medicare will not decide whether to pay unless I receive these items
or services. Please submit my claim to Medicare. I understand that you may bill me for
items or services and that I may have to pay the bill while Medicare is making its decision.
If Medicare does pay, you will refund to me any payments I made to you that are due to me.
If Medicare denies payment, I agree to be personally and fully responsible for payment.
That is, I will pay personally, either out of pocket or through any other insurance that I have.
I understand I can appeal Medicare’s decision.
_____________ _ _________________________________________
Date Signature of patient or person acting on patient’s behalf
NOTE: Your health information will be kept confidential. Any information that we collect about you on this
form will be kept confidential in our offices. If a claim is submitted to Medicare, your health information on this form
may be shared with Medicare. Your health information which Medicare sees will be kept confidential by Medicare.
OMB Approval No. 0938-0566 Form No. CMS-R-131-G (June 2002)
Assessment Quiz – Medical Necessity
To earn continuing education credit of one (1) AHIMA CEU, Fast Facts Audio Seminar listeners must also complete
this 10-question quiz. This CE credit is for attending the audio seminar AND completing this quiz. Please keep a
copy of the completed quiz with your CE certificate. Do not send a copy to AHIMA.
1. True or false? In the interest of promoting 6. True or false? Medicare rules prohibit the use of
preventive care, Medicare covers all tests for templates and pre-printed office visit forms.
screening. True
True False
False
7. True or false? Medical necessity must be clearly
2. True or false? Medicare rules state that evident in the physician’s (or non-physician
physicians are only to bill Medicare for covered practitioner’s) documentation for all tests and
services unless the claim is submitted in order to procedures submitted on the claim.
receive a denial so that the patient may be billed. True
True False
False
8. True or false? It is the coder’s responsibility to
3. True or false? In the absence of a National determine why tests and procedures were
Coverage Decision, Medicare carriers are allowed ordered, based on the diagnosis list provided by
to develop Local Coverage Decisions at their the physician/NPP.
discretion. True
True False
False
9. True or false? If a medical necessity denial is
4. True or false? The only risk that medical received from Medicare, indicating that the
necessity denials from Medicare pose to a patient is not responsible for payment, this can
Practice is the loss of revenue from write-offs. be corrected by calling the patient and obtaining
True his permission to bill him at that point, as long as
his permission is obtained in writing.
False
True
False
5. True or false? Medical necessity, based on the
patient’s medical need, is the most important
driver in the choice of E&M code selection. 10. True or false? Local Coverage Decisions (LCDs)
True may vary from Medicare carrier to carrier as to
coverage criteria.
False
True
False
Do not send a copy of completed quizzes to AHIMA. Please keep them with your CE certificate, for your records.
Be sure to sign-in and complete your evaluation form, to receive your certificate, at
http://campus.ahima.org/audio/fastfactsresources.html.
CE Certificate
visit
http://campus.ahima.org/audio/fastfactsresources.html
1: false; 2: true; 3: true; 4: false; 5: true; 6: false; 7: true; 8: false; 9: false; 10: true
Do not send a copy of your completed Fast Facts Audio Seminar quiz to AHIMA.
Please keep it with your CE certificate, for your records.