resourcebook ff2009 02 medicalnecccampus.ahima.org/audio/fastfacts/frb0704.pdfahima has no liability...

© Copyright 2009 American Health Information Management Association. All rights reserved.

Medical Necessity

Practical Tools for Seminar Learning

Disclaimer

AHIMA • http://campus.ahima.org

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The American Health Information Management Association makes no representation or guarantee with respect to the contents herein and specifically disclaims any implied guarantee of suitability for any specific purpose. AHIMA has no liability or responsibility to any person or entity with respect to any loss or damage caused by the use of this audio seminar, including but not limited to any loss of revenue, interruption of service, loss of business, or indirect damages resulting from the use of this program. AHIMA makes no guarantee that the use of this program will prevent differences of opinion or disputes with Medicare or other third party payers as to the amount that will be paid to providers of service.

How to earn one (1) CEU for participation

To earn one (1) continuing education unit, each participant must do the following: Step 1: Listen to the seminar, via Webcast link or audio CD. Step 2: Complete the assessment quiz contained in this resource book.

Use the included answer key. Do not return the quiz to AHIMA. Save it for your records.

Step 3: EACH LISTENER must visit

http://campus.ahima.org/audio/fastfactsresources.html and complete the sign-in form and the seminar evaluation.

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.

Faculty


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Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CPC-I, CHA

Shelley C. Safian, an Associate Professor for the Medical Billing and Insurance Coding program currently teaching in the online environment.

Safian is a Certified Coding Specialist-Physician-based from the American Health Information Management Association (AHIMA) and a Certified Professional Coder- Hospital and Certified Professional Coder – Instructor from the American Academy of Professional Coders (AAPC). She also holds a National Certified Insurance Coding Specialist (NCICS) designation, as well as that of Certified HIPAA Administrator (CHA).

Safian completed her Graduate Certificate in Health Care Management in June 2005 at Keller Graduate School of Management. The University of Phoenix awarded her Master of Arts/Organizational Management degree in 2002. Currently, she is working toward her PhD in Healthcare Administration.

The Florida Association of Post-secondary Schools and Colleges (FAPSC) named Safian Faculty Member of the Year 2006–2007. Herzing College, Winter Park honored Safian by naming her 2007 Teacher of the Year, and she was awarded the Faculty Scholarship Award—First Runner Up for the Herzing College System for 2006.

Safian sits on the AHIMA Classification Practice Council and is the Newsletter Chair for the Central Florida Health Information Management Association (CFHIMA).

McGraw-Hill Higher Education published Insurance Coding & Electronic Claims for the Medical Office by Safian in July, 2005. Her second, third, and fourth books, The Complete Procedure Coding Book, The Complete Diagnosis Coding Book, and You Code It! A Case Studies Workbook were published simultaneously in February, 2008. Safian’s fifth book, Essentials of Healthcare Compliance was released by Cengage/Delmar Publishing in January 2009.

Table of Contents


Disclaimer ..................................................................................................................... i How to earn one (1) CEU for participation ......................................................................... i Faculty ......................................................................................................................... ii Medical Necessity ........................................................................................................... 1 What is Medical Necessity? ............................................................................................. 1 Reasonable and Necessary ........................................................................................... 2-4 Narrowing Down the Dx .................................................................................................. 4 LCD Example .............................................................................................................. 5-6 Reimbursement Decisions ............................................................................................... 7 Understanding the Difference ....................................................................................... 7-8 A Case Study .............................................................................................................. 8-9 Documentation Requirements ........................................................................................ 10 Evidence-based Medicine ............................................................................................... 10 Basis to Challenge ......................................................................................................... 11 Create Your Own Guidance ............................................................................................ 11 Resource/Reference List ................................................................................................ 12 AHIMA Audio Seminars/Webinars ................................................................................... 13 About assessment quiz .................................................................................................. 13 Thank you for attending (with link for evaluation survey) ................................................. 14 Appendix .................................................................................................................. 15 Web Resource List Assessment Quiz CE Certificate and Sign-in Instructions Quiz Answer Key

Medical Necessity

AHIMA • http://campus.ahima.org 1

Notes/Comments

Medical Necessity

“Medical necessity refers to a determination that a treatment, test, or procedure is necessary to a person's health or to treat a diagnosed medical problem. Cosmetic procedures, for instance, are not covered under medical necessity provisions.”

Journal of the American Medical AssociationVol. 297 No. 10, March 14, 2007

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What is Medical Necessity?

It [A service, treatment, or procedure] is reasonable and necessary under 1862(a)(1)(A) of The Act.

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Medical Necessity


Notes/Comments

Reasonable and Necessary

“Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:

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Safe and effective; Not experimental or investigational and …

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Medical Necessity


Notes/Comments


Appropriate duration and frequencyFurnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body member;

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Furnished in a setting appropriate to the patient's medical needs and condition;Ordered and furnished by qualified personnel;

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Medical Necessity


Notes/Comments


One that meets, but does not exceed, the patient's medical need; and At least as beneficial as an existing and available medically appropriate alternative

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Narrowing Down the Dx

to identify diagnoses considered “reasonable and necessary” for a specific procedure

NCD

LCD

Use National Coverage Determinations

and Local Coverage Determinations

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Medical Necessity


Notes/Comments

LCD Example

Coverage Topic:Immunosuppressive DrugsThis therapy is generally reserved for patients with significant relapsing, subacute to chronic symptoms, where the symptoms are likely caused by allergic pathology, and in situations where other means of conservative therapy (including avoidance) have failed to control the symptoms adequately, or avoidance of the relevant allergen (e.g., dust mites, pollen, mold) is impractical.

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LCD Example (continued)

Medicare will provide coverage for allergen immunotherapy for patients with allergic rhinitis, allergic conjunctivitis, asthma, or a previous anaphylactic reaction to a stinging/biting insect or other arthropod when all four of the following criteria are met:

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Medical Necessity


Notes/Comments


1. The patient must have significant exposure to an allergen;2. The patient must have demonstrated a significant level of

sensitivity to the allergen;3. The pattern of symptoms must conform to the pattern of

exposure; and

4. Other means of conservative therapy (including avoidance) have failed to control the symptoms, or avoidance of the relevant antigen (e.g., dust mites, pollen, mold) is impractical.

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ICD-9 Codes that Support Medical Necessity

372.05 ACUTE ATOPIC CONJUNCTIVITIS

372.14 OTHER CHRONIC ALLERGIC CONJUNCTIVITIS

477.0 ALLERGIC RHINITIS DUE TO POLLEN

477.2 ALLERGIC RHINITIS, DUE TO ANIMAL (CAT) (DOG) HAIR AND DANDER

477.8 ALLERGIC RHINITIS DUE TO OTHER ALLERGEN

493.00 - 493.02 EXTRINSIC ASTHMA UNSPECIFIED –EXTRINSIC ASTHMA WITH (ACUTE) EXACERBATION

493.90 - 493.92 ASTHMA UNSPECIFIED –ASTHMA UNSPECIFIED WITH (ACUTE) EXACERBATION

989.5 TOXIC EFFECT OF VENOM

995.0 OTHER ANAPHYLACTIC SHOCK NOT ELSEWHERE CLASSIFIED

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Medical Necessity


Notes/Comments

Reimbursement Decisions

Recognize the difference between a

• Medical Necessity Decision

• Coverage Decision

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Understanding the Difference

Medical Necessityfor coverage and payment

• “The service is required for the prevention, identification, treatment, or management of a condition”

• Not according to AMA or standards of care, but as per third-party payer

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Medical Necessity


Notes/Comments

Understanding the Difference

Coverage Decisions

• A decision based on the specific details of an individual’s policy regarding categories of health interventions as provided within the terms of the contract between plan and policyholder

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A Case Study

After all these years, Harold’s bunion is too painful and now interferes with his ability to walk. Dr. Harrison recommends a bunionectomy to resolve the condition.Harold is covered by ABC Insurance.

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Medical Necessity


Notes/Comments

A Case Study

Esther is finding that her left foot is hurting and affecting her ability to walk. Dr. Harrison diagnoses her with a bunion and recommends a bunionectomy to resolve the condition.Esther is covered by ABC Insurance.

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A Case Study

Claims were submitted for the same procedure with the same diagnosis code to the same third-party payer for both Harold and EstherHarold’s claim was deniedEsther’s claim was paid in full

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Medical Necessity


Notes/Comments

Documentation Requirements

“Medical record documentation maintained by the treating physician must clearly document the medical necessity to initiate” the treatment

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Evidenced-based Medicine

NCD and LCD are not absoluteAppeals can be made supported by a hierarchy of evidence

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Medical Necessity


Notes/Comments

Basis To Challenge

Published authoritative evidence derived from definitive randomized clinical trials or other definitive studies, andGeneral acceptance by the medical community (standard of practice), as supported by sound medical evidence based on: • Scientific data or research studies published in peer-

reviewed medical journals;

• Consensus of expert medical opinion (i.e., recognized authorities in the field); or

• Medical opinion derived from consultations with medical associations or other health care experts.

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Create Your Own Guidance

Find NCD/LCD and coverage policies for the most common treatments, services, and procedures provided by your office, clinic, or facilityCreate an easy-to-access reference tool (binder, database, folder, etc.)Update annually

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Medical Necessity


Notes/Comments

Resource/Reference List

www.cms.hhs.gov• Click on MEDICARE• Scroll down to COVERAGE (lower left)• Click on MEDICARE COVERAGE –

GENERAL INFORMATION• Choose MEDICARE COVERAGE

DATABASE• Click on INDEXES

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Resource/Reference List

mcgs.bcbsfl.com• Blue Cross Blue Shield of Florida

Medical Coverage Guidelines• Similar to LCDs for Medicare

This is an example. Virtually all private third-party payers have similar sections on their websites.

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Medical Necessity


Notes/Comments

AHIMA Audio Seminars/Webinars

Visit our Web site http://campus.AHIMA.orgfor updated information on the current seminar schedule. While online, you can also register for live seminars or order CDs and Webcasts of past seminars.

© 2009 American Health Information Management Association

Assessment

To access the assessment quiz that follows this seminar, download the seminar’s resource book at

http://campus.ahima.org/audio/fastfactsresources.html

Medical Necessity


Notes/Comments

Thank you!

Please visit the AHIMA Audio Seminars Web site to sign-in and complete your evaluation form to receive your CEU certificate at:

http://campus.ahima.org/audio/fastfactsresources.html

Appendix


Web Resource List Assessment Quiz CE Certificate and Sign-in Instructions Quiz Answer Key

Appendix


Web Resource List www.cms.hhs.gov Click on MEDICARE Scroll down to COVERAGE (lower left) Click on MEDICARE COVERAGE – GENERAL INFORMATION Choose MEDICARE COVERAGE DATABASE Click on INDEXES

mcgs.bcbsfl.com • Blue Cross Blue Shield of Florida Medical Coverage Guidelines • Similar to LCDs for Medicare This is an example. Virtually all private third-party payers have similar sections on their websites.

Assessment Quiz – Medical Necessity

AHIMA • http://campus.ahima.org ANSWERS to this quiz are found on the last page of the seminar resource book, Practical Tools for Seminar Learning.

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. Reasonable and necessary procedures include all

of the following except: a. Safe and effective b. Appropriate duration c. Experimental or investigational d. In accordance with standards of medical

practice 2. National Coverage Determinations __________

medical necessity for procedures and services. a. never identify specific ICD-9 codes that

support b. always identify specific ICD-9 codes that

support c. are vague about which diagnoses are

considered d. leave determinations to LCDs about

3. True or false? Medical necessity is defined as a

treatment that is necessary to a person’s health. a. True b. False

4. True or false? A Medicare LCD specifies the

details regarding coverage of specific diagnoses and procedures applicable to all Medicare beneficiaries in the continental United States. a. True b. False

5. True or false? Coverage decisions are solely

based on whether or not the AMA has identified a procedure to be medically necessary for a specific diagnosis. a. True b. False

6. To support medical necessity, documentation

needs to include a. Diagnostic statement b. H&P c. Progress notes stating anticipated treatment

plan d. All of the above

7. Access to NCD and LCD is

a. Restricted by password b. Available only to hospitals c. Available to everyone d. All of the above

8. Once a claim is denied for medical necessity,

a. The decision may be appealed with supporting evidence

b. The decision is absolute and must be accepted

c. Requires new clinical trials to overturn d. Requires an act of Congress

9. True or false? Medicare is the only third-party

payer that publishes coverage guidelines, such as LCDs. a. True b. False

10. True or false? Medical necessity as per the

standards of care is not the same thing as medical necessity as per third-party payers. a. True b. 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.

To receive your

CE Certificate

visit http://campus.ahima.org/audio/fastfactsresources.html

click on the link to

“Sign In and Complete Online Evaluation” listed for this seminar.

You will be automatically linked to the

CE certificate for this seminar after completing the evaluation.

Each participant expecting to receive continuing education credit must complete the online evaluation and sign-in information,

in order to view and print the CE certificate.


Quiz Answer Key Fast Facts Audio Seminar: Medical Necessity 1: c; 2: b; 3: true; 4: false; 5: false; 6: d; 7: c; 8: a; 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.

resourcebook ff2009 02 medicalnecccampus.ahima.org/audio/fastfacts/frb0704.pdfahima has no liability...

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