This term has different means\ndepending on its usage. Many are inter-related.<\/p>\n\n\n\n
Clinical:<\/strong> It refers to whether treatment of a disease or condition is\nwarranted medically. This is in regard to published Clinical Practice\nGuidelines (CPGs) for care for a particular condition. There are clinical\nguidelines for many conditions including diabetes, IBS, BPH, chronic pain management\nand many others; it has nothing to do with reimbursement\u2013but what is medically\nwarranted. High-quality, evidence-informed clinical practice guidelines (CPGs)\noffer a way of bridging the gap between policy, best practice, local contexts\nand patient choice. A long list of guidelines for many conditions is listed\nbelow as an example:<\/p>\n\n\n\n https:\/\/nccih.nih.gov\/health\/providers\/clinicalpractice.htm<\/a><\/p>\n\n\n\n These are important because all\nmedical insurance companies use the strength of the research, and subsequent\nguidelines related to services and procedures to create reimbursement policy.<\/p>\n\n\n\n Reimbursement:<\/strong> Based on the clinical efficacy and outcomes\nresearch, medical necessity is what determines if a service or procedure for a\nspecific diagnosis is reimbursed by a medical insurance carrier. Medicare has\nnumerous Local Coverage Determinations (LCD\u2019s) that outline specific procedures\nand a list of ICD-10 codes that support medical necessity. Some procedures are\ndetermined to be cosmetic, designed to improve appearance or psychological\nwell-being and therefore not considered to be medically necessary. Some cosmetic\nprocedures can be determined to be reconstructive based on the ICD-10 or\nspecific circumstances.<\/p>\n\n\n\n To be considered reconstructive\n(and medically necessary) the procedure must be proven to:<\/p>\n\n\n\n Do\nnot<\/em> include the psychological benefits from the procedure. This is\nstatutorily documented in numerous policies as \u201cnot supporting medical\nnecessity.\u201d<\/p>\n\n\n\n A service or procedure must be\ndetermined to not be<\/em> experimental,\ninvestigative, or unproven. These terms are also often used as either\njustifying or not justifying medically necessary. Most healthcare carriers have\na specific policy concerning what they consider experimental, investigative, or\nunproven.<\/p>\n\n\n\n Another factor impacting whether a\nprocedure or service is medically necessary is whether the patient is well enough<\/em> to tolerate the procedure.\nIf the patient has significant comorbidities then he\/she may not be well enough\nto be approved for surgery based on the \u201cmedical necessity\u201d of performing the\nprocedure versus not performing it.<\/p>\n\n\n\n Another coding and documentation\nuse of medical necessity is the selection and use of office visit codes. Per\nMedicare, medical necessity determines the level and frequency of office visit\ncodes. In other words, more complex, worsening, and severe conditions warrant\nhigher level codes than simple and self-limited ones. This term has different means depending on its usage. Many are inter-related. Clinical: It refers to whether treatment of a disease or condition is warranted medically. This is in regard to published Clinical Practice Guidelines (CPGs) for care for a particular condition. There are clinical guidelines for many conditions including… Continue reading
<\/p>\n","protected":false},"excerpt":{"rendered":"