Question:

What is the difference between medical necessity and medical decision-making?

Answer:

In a February 1, 2018 RACmonitor article, David Glaser, Esq., answered this question as follows: “Medical necessity is the idea that insurance won’t pay for a service a patient doesn’t need. That’s a very basic and reasonable principle in insurance. Medical decision-making is an attempt to create a formula to quantify the amount of effort a medical professional expends on evaluating a patient. The methodology for evaluating medical decision-making is contained both in the CPT® book and in the Centers for Medicare & Medicaid Services (CMS) E&M documentation guidelines.”

For the article, go to https://www.racmonitor.com/warning-medical-decision-making-and-medical-necessity-not-one-and-the-same.


CPT® is a registered trademark of the American Medical Association.

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Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

CPT is a registered trademark of the American Medical Association.