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Verifying Medical reasonableness

Duang Posted Fri 25th of January, 2019 13:12:11 PM
Do you know what criteria(s) that the claims system(s) use to check the “medical reasonableness” when a claim is adjudicated? I am trying to see how I can identify the medical reasonableness by looking at only UB-04. Much appreciated for any input/suggestions.
Duang Posted Fri 25th of January, 2019 21:26:33 PM
Hi, would anybody be able to give me some information on interpretation on UB-04? By looking at the CPT code, ICD-10-CM/ICD-10-PCS, can we determine/identify medical reasonableness?? Also, Is it possible to verify if the total charge for an inpatient claim is reasonable? I would appreciate any thought/input. Thank you! Duang
SuperCoder Answered Mon 28th of January, 2019 07:27:35 AM

Hi Duang,

Thanks for your question.

Medicare covers those services which are medically necessary. According to CMS, “medically necessary” is defined as “Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.”


Medical reasonableness or medical necessity of a procedure is determined by looking at LCD (Local Coverage Determinations) or NCD (National Coverage Determinations). LCD/NCD are developed by CMS and contain medically reasonable ICD 10 cross-codes for each procedure code (CPT code).


Now for total charges of a procedure, you need to look at OPPS fee schedule provided by CMS. A fixed amount is attached with each CPT code.


By just looking at form UB-04, medical necessity cannot be identified. Though it can be judged up to some extent with experience. Example, if the physician has performed appendectomy, it means patient must have appendicitis. So, the diagnosis code of appendicitis would be appropriate for procedure appendectomy.


Please feel free to write if you have any question.



Duang Posted Mon 28th of January, 2019 10:08:16 AM
Thanks so much for your answer. It's very helpful. When you said, the medical necessity can be judged up to some extent with experience. What are you specially referring to? Do you have to be at least a nurse or a doctor? Let's say a patient was admitted with a finger fracture, then ended up with open heart surgery (final Dx). How can a coder use their experience to judge this case?
SuperCoder Answered Tue 29th of January, 2019 02:39:35 AM

Thanks for your question. Please find the answer below:


You do not have to be a nurse or a doctor but an experience medical coder. Let us discuss the example given by you:


A patient has a fractured finger. We know that the doctor will repair the finger fracture. He can order an x-ray to look where the fracture is. Then he can repair the fracture either closed (with manipulation and cast) or he can open the fracture site with incision to align the bones and fix them with the screws etc. We all know that heart surgery cannot be performed for finger fracture. This would be unreasonable.


Another example is: A physician has performed appendectomy. By this, we can make out that the patient may have the disease of appendix (e.g. appendicitis). So, one can judge that the diagnosis code for appendicitis would be medically reasonable for procedure appendectomy. So, you do not need to check LCD/NCD every time to check medical necessity.


Hope this helps.



Duang Posted Tue 29th of January, 2019 20:52:22 PM
What a great answer! thanks so much. Very helpful info...
SuperCoder Answered Wed 30th of January, 2019 00:36:42 AM

Thank you, happy to help.

Duang Posted Wed 29th of April, 2020 10:32:57 AM
This is regarding a PCS code representing the device or drug that links to box 74 on the UB04. Example PCS codes are "XW033C3" or "ZW033H4" or "XW033N5"...If a patient has 3 drugs on 3 different dates, do they use one PCS code for each treatment/day or should it be one combined code that covers all 3 days? Does that impact the payment? Does the coder usually code the PCS code for each day that the drug is administered?
SuperCoder Answered Thu 30th of April, 2020 09:25:35 AM
This new post in not related to the previously responded query. Multiple queries cannot be answered on a single thread. Please post this query in a new thread.

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