General Question for the Week of May 27, 2024

Question:

In general, do you have any tips for correctly documenting medical necessity?

Answer:

Documentation supporting medical necessity should be legible, maintained in the patient’s medical record, and made available to auditors upon request. Indications for diagnostic studies or therapeutic procedures should be clearly described in clinical records and available for review. All providers of pulmonary function tests should have a referral (a prescription) with clinical diagnoses and requested tests on file. On that note, the following must be addressed: All equipment and studies should meet the minimum standards outlined by the American Thoracic Society. Spirometry studies, in particular, require a minimum of three attempts that must meet minimum acceptability criteria. All studies require an interpretation with a written report. Computerized reports must have a physician’s or other QHP’s signature attesting to their accuracy. In addition to those listed above, the frequency of inhalation therapy and mode of administration should be designated by a physician or other QHP, along with a treatment plan for chronic conditions.

This question was answered in our Coding Essentials for RT/Pulmonary Function. For more hot topics relating to respiratory services, please visit our store or call us at 1.800.252.1578, ext. 2.

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