Understanding medical necessity from a coding, documentation and appeals perspective can seem like a constantly moving target. Does medical necessity apply to services performed – or services billed? And who is qualified to judge the medical necessity of a service?
“Medical necessity” is generally understood to refer to the requirement that medical services be justifiably reasonable, necessary and appropriate and is inextricably linked to the modern phenomenon of payer-based healthcare. But there’s no universally accepted definition of the term, and providers, coders, private payers, the Centers for Medicare & Medicaid Services (CMS) and patients alike struggle with the concept on a daily basis in the U.S. healthcare system.
This guide will help coders identify and define key aspects of medical necessity, ensure proper coding and documentation to support it, and craft effective appeals.