Posts tagged ‘medical necessity’

January 19, 2011

Followup on PT/INR … the flipside

Shortly after I posted on PT/INR, I received a question about what to do when the PT/INR fluctuates, which makes the Coumadin dosing also fluctuate. Is that enough to keep a patient admitted in home health?
Medical necessity is the key. In this case, the medically necessary service that you’re providing is observation and assessment. O and A is medically necessary when there exists a potential fluctuating condition that requires the skills of a nurse to assess and intervene.

Document well.

January 6, 2011


It’s winter, and that means B12 rumors and questions.

CMS has a web page that deals with B12, and includes ICD-9 codes that support the medical necessity of using B12 injections. These include pernicious anemia, 281.0; other vitamin B12 deficiency anemia, 281.1; malignant neoplasm of trachea, 162.0-162.9; regional enteritis unspecific, 555.9, among other codes.

Note on this page that there are no codes listed under the heading ICD-9 Codes That Do Not Support Medical Necessity.

The key, as always, is documentation. The list from CMS is useful, but as long as you can show your medical need, you should be able to get coverage. Here is what CMS says regarding documentation:

Documentation supporting medical necessity of this item, such as ICD-9-CM codes, must be submitted with each claim. Claims submitted without such evidence will be denied as being not medically necessary. It is expected that documentation, if requested and reviewed, will reflect abnormally low B12 levels by testing.

Documentation supporting the medical necessity should be legible, maintained in the patient’s medical record, and must be made available to the Intermediary upon request.
Check out the B12 page here.