5. A: Medical Necessity
Rationale: Per the Medicare Claims Processing Manual, Chapter 12, Physicians/Nonphysician Practitioners, Section 30.6.1.A, “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted.”2 When medical necessity is demonstrated, however, medical decision making (MDM) is often the “pointer” in determining the level of service. Note, CPT guidelines do not specifically require MDM to be considered when two of three components must be met for a given service level; however, many coders interpret the discussion on medical necessity in Section 1862(a)(1)(A) of the Social Security Act to mean that MDM must be one of the two key components. In addition, instruction from the American Medical Association in CPT Assistant implies that the history or exam elements should be recorded only to the extent that MDM requires them.
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6. B: False
Rationale: Per CMS, “In coding individual claims, it will be more efficient and accurate to work from the medical record documentation and then select the appropriate code(s),” rather than attempt to translate information from one code set to the other.3 Keep in mind, there is not a one-to-one match between ICD-9-CM and ICD-10-CM … there are instances where there is no plausible translation from a code in one system to any code in the other system. The safest method to choose a correct diagnosis code is using both the alphabetical index and tabular list of the official ICD-10-CM manual. Tip: As always, never code strictly from the alphabetical index. Always confirm your code choice in the tabular list to ensure the most appropriate code is selected for billing.
For questions or additional information on coding and billing for your practice, contact Melesia Tillman at email@example.com or 404-633-3777 x820.
- National Correct Coding Initiative Policy Manual for Medicare Services. American Medical Association. 2016 Jan 1.
- Medicare Claims Processing Manual. Chapter 12—Physicians/Nonphysician Practitioners. (Rev. 3402, 11-06-15).
- General Equivalence Mappings: Frequently Asked Questions. Department of Health and Human Services, Centers for Medicare and Medicaid Services. 2015 June.