Posted on 20. Apr, 2009 by in Hot Coding Topics
Establish dual necessity to unlock MAC reimbursement.
If your anesthesiologist is having trouble getting Medicare reimbursement for monitored anesthesia care (MAC) for endoscopy procedures, it might be time to clarify exactly what is meant by “medical necessity.”
Medicare defines “medical necessity” as services or items reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Under the Social Security Act, CMS determines on a case-by-case basis if the method of treating a patient is reasonable and necessary. Even if a service is reasonable and necessary, coverage may be limited or denied if it is provided more frequently than allowed under a coverage policy, or as accepted standard of practice.
First: Establish Necessity for Endoscopy
CMS states that endoscopic procedures — a technique in which a long flexible tube-like instrument is inserted into the body orally or rectally — are covered when reasonable and necessary for the individual patient.
Circumstances that establish the medical necessity for endoscopic procedures are patients who have more complex procedures such as endoscopic retrograde cholangiopancreatography (ERCP) or endoscopic ultrasound (EUS); patients who are pregnant; patients who have cancer, epilepsy, or seizure disorders; children 18 years or younger; and seniors 65 or older, says Darlene Ogbuagu, CPC, ACS-AN, in Chicago.
In addition, patients with danger of airway compromise with a history of sleep apnea, Down syndrome, oral abnormalities, and/or patients who are combative, abuse drugs, or have intolerance to sedatives may require endoscopy, Ogbuagu says.
Next: Reasons for MAC Establish Necessity
The patient should have a medical condition...
- Free updates on CPT, ICD-9, HCPCS, Medicare, NCCI edits, and ICD-10.
- Discounts on 3rd party offers