Understanding Medical Necessity Data vs. Software Tools

I was asked recently if the medical necessity data files that 3M calls ‘medical necessity dictionaries’ are the same as products that have medical necessity checking capabilities. It’s really a great question and if you are not in the software or data creation business it certainly can be confusing.

The medical necessity dictionaries are data files that 3M creates to mirror the CMS National Coverage Determinations (NCD) policies. Data is also created to represent Local Coverage Determination (LCD) policies created by the MAC (Medicare Administrative Contractors) vendors. The data files are content used in vendor, payer and hospital software systems.

A brief overview of the differences:

Data or content: 3M collects data available in the public domain directly from organizations that create it, such as CMS. We use this information to create medical necessity content. The raw data is carefully reviewed by our team of highly skilled analysts. Once it passes internal scrutiny it is formatted into different data products and delivered to our customers, including large vendors of electronic health records, healthcare systems, hospitals, group practices, private and public payers, billing and coding vendors, large government entities, and even governments of other countries. The ICD-9 (ICD-10 data is available for testing purposes) and CPT/HCPCS codes in our data products (3M Medical Necessity Dictionaries and 3M Medical Necessity Data Files) are loaded into their systems. Our partners include the data in their products and systems to help their users perform medical necessity checking/coding/billing tasks.

Software tools: In addition to creating medical necessity data, 3M also builds proprietary software tools that utilize this data and other content. Some of the tools that contain our medical necessity data include 3M APCFinder Software and the 3M Ambulatory Revenue Management System. Like all vendors, we continually evaluate our software products. While we may modify our software to meet client needs, develop new products that take advantage of technology breakthroughs, or retire software applications to support changing business requirements, the process of creating the content or data driving our software remains the same. Regulations and new laws that impact coverage, utilization, new codes and clinical requirements all impact data. 3M delivers medical necessity updates every two weeks to ensure our partners and their users have the latest regulatory and coding changes. 3M’s software tools may evolve, but it does not impact our promise to deliver medical necessity data to all our Dictionary and Data File customers.

Barbara Aubry is a Regulatory Analyst for 3M Health Information Systems.

2 responses to “Understanding Medical Necessity Data vs. Software Tools

  1. Can you provide examples of “Medical Necessity” criteria, say for cancer chemotherapy after failing same twice or a MRI of the knee one day after a minor injury producing a mild-moderate limp

  2. Hello Dr Kaplan –

    Thank you for your comment. You may not be aware that we do not author medical necessity criteria. You can view information on medical review criteria on the CMS website (http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/index.html?redirect=/Medical-Review).

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