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


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.”

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CPT is a registered trademark of the American Medical Association.