Corporate Compliance

Tip: Help physicians learn to perform a medical necessity check

Compliance Monitor, March 2, 2005

Before performing a medical-necessity check, be sure physicians review test orders for all required elements and identify the reasons for the test. Ask them to use the following steps to verify medical necessity:

1. Determine whether the test or service ordered has an NCD or LCD.

2. If the test or service does not have limited coverage under an NCD or LCD, facilities can proceed and perform the test(s) ordered.

3. If the test or service to be performed does have limited coverage under an NCD or LCD, review the signs, symptoms, or diagnosis you have provided and determine whether your documentation supports medical necessity by reviewing the list of ICD-9-CM codes that support medical necessity.

4. If the test or service provided does not meet medical necessity requirements and is not on the covered list of ICD-9-CM codes, complete an ABN.

5. For those tests that have frequency limitations, review the appropriate section of the NCD or LCD for those specific limitations. Obtain an ABN when the patient exceeds frequency limitations.

This tip was excerpted from HCPro's Medical Necessity Training Handbook for Physicians. Copyright 2004 by HCPro Inc. To learn more, click here.

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