Question

6. Define medical necessity as it applies to procedural and diagnostic coding. (IX.C.5) 7.Describe how to use the most current procedural coding system. (IX.C.1)

Answer 1

6. Medical necessity can be defined as any healthcare service provided by a physician with reasonable clinical judgment to a patient. This healthcare service should be for the evaluation, diagnosis, or treatment of an illness or injury. Medical necessity is a comprehensive essential for a medical service, and diagnostic coding (ICD) and procedural (CPT) coding are used to specify the medical necessity. The procedural code describes the procedures undergone by the patient during the healthcare facility visit, which includes laboratory, diagnostic, radiology, and surgical procedures whereas the diagnostic code indicates a physician’s diagnosis with description of a disease or medical condition. These codes are used to determine medical necessity during the billing process.

7. The most current procedural coding system is used effectively by reading, analyzing, and abstracting the services or procedures documented in the patient’s health record. This is then compared with the operative report or any other patient-detail documentation to ensure that all procedures are recorded. After conducting an alphabetic index search of the CPT codes, check for the appropriate codes in the list, and assign the most accurate codes. The CPT (Current Procedural Terminology) codes have five characters, which are mostly numeric or with a 5th alpha character.