Experience. Integrity. Advocacy.
Experience. Integrity. Advocacy.

Code Updates, Policy Changes Offer Reminder to Document Medical Necessity

For 2018, five new codes were created and adopted by the Centers for Medicare and Medicaid Services (CMS) for billing anesthesia services during endoscopic procedures. According to CMS, the change was a reflection of how common it is for anesthesia to be administered during screening colonoscopies and other gastroenterology procedures. But it’s also why some payers are looking more closely at the medical necessity of such services.

In an update to its policy CG-MED-34, “Monitored Anesthesia Care for Gastrointestinal Endoscopic Procedures,” Anthem recently added the new GI codes, while also reiterating its guidelines for medical necessity of monitored anesthesia care during endoscopic procedures, citing circumstances such as

  • Individuals over 70; or
  • Individuals under the age of 18; or
  • Pregnancy; or
  • History of drug or alcohol abuse; or
  • For a complete list, review CG-MED-34.

In another recent policy change, Anthem announced it would no longer cover general anesthesia or Monitored Anesthesia Care (MAC) during most cataract surgeries. While they offered a list of exceptions, the payer claimed in their recently published clinical guidelines that in most instances general anesthesia is not medically necessary.

While several national physician organizations have been appealing to Anthem to reverse this and other policies, in the meantime, physicians would do well to heed these changes as a reminder of the importance of documenting medical necessity.

Impacting Error Rates

According to Indiana’s Medicare Administrative Contractor, WPS-GHA, “insufficient documentation continues to have a large impact on error rates for WPS Medicare and on a national level.”

They recommend including the following elements in the anesthesia record as a baseline for supporting “the medical necessity and level of service(s) billed in accordance with Medicare regulations and policies.”

  • Clear indication of patient name, date of birth, and date of service
  • Documentation supporting diagnosis billed
  • Pre anesthetic exam and evaluation
  • Intra operative report with documentation of anesthesia time
  • Operative report
  • Post-anesthesia report

Beyond the Diagnosis

In their Timely Topics article called “Practice Management Tips and Tools – Determining Medical Necessity,” the American Society of Anesthesiologists (ASA) also reminds physicians that National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) provide guidance to help providers understand Medicare and MAC requirements for medical necessity for specific procedures.

“These coverage documents typically outline the service/treatment and documentation requirements, including a listing of what conditions or symptoms indicate the service is warranted, any procedural requirements and if there are limitations to the coverage,” the ASA explains. “If there are NCDs and LCDs specific to the service you are providing, you can refer to them to determine if the ICD-10-CM code you are using is in the covered or non-covered listing of codes or other description information.”

But even those guidelines allow some room for interpretation. In fact, while the diagnosis may explain the need for the procedure itself, the justification for the type of anesthesia being used often is contingent on other factors, like comorbidities, age, and medical or social history. Clearly documenting these and other factors that helped determine why one particular type of anesthesia was chosen over others is important in the case of a medical necessity denial or review, especially for payers with specific medical necessity policies.

Will You Get Paid or Not?

Ultimately, it’s the medical record documentation that will determine if the claim will be paid, the ASA concludes.

“You can help demonstrate the medical necessity of the care you provide by making sure your clinical documentation tells a complete and accurate story of your patient’s actual condition, shows why the services would improve that condition, and validates the ICD-10-CM code reported on your claims,” the article claims. “Establishing that the services were reasonable and necessary is a requirement for payment. Reviewing the coverage documents, your documentation and the coding on your claims to ensure the medical necessity guidelines are met will help reduce disruption in your revenue flow.”

So as coding guidelines are updated and payer policies are changed, it’s more important than ever to not only document what services you provided for the patient, but also why. Getting paid for your work depends on it.

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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