A medically necessary service must prove to be reasonable and necessary to diagnose or treat a patient’s medical condition. Furthermore, the diagnosis code(s) reported (on the claim) with the service rendered is to justify (to a payer) “why” a service was performed. The diagnosis reported can determine the medical necessity of the procedure.
Clinicians must understand the rules and regulations that guide the wound care department’s documentation and billing processes. The rules within the wound care department are generated from your Fiscal Intermediary, Carriers, and Medicare Administrative Contractors (MACs); National Coverage Determinations (NCD); respective Local Coverage Decisions (LCD); Centers for Medicare & Medicaid Services (CMS); The Joint Commission; American Medical Association; and so on. It is important to have processes in place to ensure your documentation supports the rules of medical necessity.
Read the rest of this article in Advances in Skin & Wound Care.
An excerpt from an article originally published in Advances in Skin & Wound Care, written by Cathy Thomas Hess, BSN, RN, CWCN, VP and Chief Clinical Officer for Wound Care at Net Health.