Medical Necessity and Cloning

By: Barbara Aubry

I recently read a great article from Report on Medicare Compliance by Nina Youngstrom titled “Medicare Watchdogs, Compliance Officers Investigate ‘Carry Forward’” that brought back memories of my days as a Utilization Review nurse. As the article reminds us, CMS has no hard and fast national position on the use of electronic (or manual for that matter) medical record short cuts such as templates or the ubiquitous cut-and-paste transfer of patient data from one encounter to the next. Click here to learn more. While a definite time-saver, this habit does present compliance issues that payers are beginning to notice.  And some are going so far as to wonder — if your documentation does not change from one date of service to the next — are those visits really medically necessary?

Medical Necessity: More Than a CPT and ICD Code Pair

By: Barbara Aubry

In real estate, value is determined by three things — location, location and location. In my opinion, a similar adage should be created for determining the value of medical services. Medical necessity is based on three things – documentation, documentation and documentation. It’s more than pairing a CPT and ICD code that will pass your claim scrubber. It’s even more than making a patient feel better.

On July 28, 2011, Daniel R. Levinson, Inspector General, U.S. Department of Health and Human Services testified that “medically unnecessary services are particularly concerning as beneficiaries may be subjected to tests and treatments that serve no purpose and may even cause harm.”