Understand the intricacies of medical necessity
Recovery Auditor Report, January 22, 2009
Notwithstanding any other provisions of this tile, no payment may be made under Part A or Part B for any expenses incurred for items or services, which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
Screening criteria such as Interqual Level of Care and Millman Care Guidelines are intended merely as screening guidelines, are not dispositive on the issue of existence of medical necessity with respect to any particular claim, and do not eliminate the need to utilize independent clinical judgment when reviewing claims. Further, these criteria reflect clinical interpretation and analyses, and cannot alone provide the sole basis for definitive decisions.
Editor’s note: Krauss is a senior coding and chargemaster consultant for QHR in Brentwood, TN. This information was adapted from a January 14 article in JustCoding.com.
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