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The Importance of Medical Necessity in Medical Coding/Billing

Procedures and the reasons for performing them are at the heart of medical necessity and it’s the medical coder and biller’s job to properly explain them in a claim by selecting the correct codes. Put simply, the payer will absolutely, without fail, pay only for those procedures that are deemed medically necessary.

For that reason, if you want the payer to approve payment (and you do), then you must make sure that the reason behind every procedure a medical professional performs is valid. For example, if the diagnosis code specifies a broken foot, the payer will pay only for the broken foot, not for a shoulder repair, even if both happened in the same accident. The diagnosis must fit the procedure.

It’s not your responsibility as the coder to make up a payable diagnosis; it’s your responsibility to verify that the diagnosis in the chart supports the procedure being billed. If you think the chart does not reflect the correct procedure, ask for clarification.

Never make an assumption about what you think the physician meant to say. Take the time to follow up on any questions you have about the chart in question. Doing so saves you time and trouble later.

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