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Criteria to determine medical necessity

Primary Task Response: Within the Discussion Board area, write 200–250 words that respond to the following questions with your thoughts, ideas, and comments. This will be the foundation for future discussions by your classmates. Be substantive and clear, and use examples to reinforce your ideas.

Accurate coding and billing are essential to a health care facility and to a physician’s financial survival. Coding is a complex task that ties to charges and revenue generation. Failure to capture all charges associated with a patient encounter can result in significant revenue loss. Medical necessity also plays a vital role in the contract with the facility or physician in terms of receiving payment from the third-party payer (e.g., an insurance company).

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Part 1

For this Discussion Board, define the term medical necessity, and describe the criteria to determine it.

Part 2

Once the patient has an established diagnosis and the services and procedures have been ordered, they will be assigned codes and placed on the claim for payment.

It is important for health care professionals to understand this process to receive accurate reimbursement. Consider the following questions:

  • Why is it important to assign the correct codes to the diagnoses, services, and procedures that a patient has received?
  • What are the repercussions of submitting incorrect coding and billing errors to the third-party payers?

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