Medical Necessity
CPT-4 (used for physician services) and ICD-9-CM (used for diagnoses) coding systems are assigned based strictly on documentation. Because of this, we need to be sure to have all services documented, including the reason for each service.
(NOTE: "Probable", "rule-out" and "possible" diagnoses may be indicated in your documentation, but they cannot be coded. Instead, the sign or symptom should also be documented and this will be the information used for coding.)
The diagnosis or reason for a service must be documented within the medical record for the current episode of care. An episode of care is defined by the specific date of service for an outpatient service or the dates starting with the admit date going through to the discharge date for inpatient services. |
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