Certified Medical Assistant (CMA AAMA)Administrative: Billing, Coding and SchedulingHard
A medical assistant is reviewing a denial for a claim submitted for a patient's annual wellness visit. The reason for denial states 'lack of medical necessity.' The physician's documentation clearly indicates the patient's eligibility for the service. Which of the following is the most likely reason for this denial?
- AThe CPT code used was incorrect for an annual wellness visit.
- BThe claim was submitted after the timely filing limit.
- CThe ICD-10-CM code used did not support the medical necessity for the CPT code.
- DThe patient's insurance policy does not cover annual wellness visits.
Show answer & explanationAnswer & explanation
Correct answer: C. The ICD-10-CM code used did not support the medical necessity for the CPT code.
A 'lack of medical necessity' denial often indicates that the diagnosis code (ICD-10-CM) submitted on the claim does not align with or support the procedure code (CPT) as medically necessary for the patient's condition. For annual wellness visits, specific preventive diagnosis codes are required.
Why the other options are wrong
- A. An incorrect CPT code would likely result in a denial for 'invalid code' or 'service not covered,' not specifically 'lack of medical necessity.'
- B. A claim submitted past the timely filing limit would be denied for 'timely filing limit exceeded,' not 'lack of medical necessity.'
- D. If the policy didn't cover wellness visits, the denial reason would typically state 'service not covered' or 'benefit maximum reached,' not 'lack of medical necessity.'
Medical Necessity Denial
A claim denial indicating that the services provided were not deemed reasonable and essential for the diagnosis or treatment of an illness or injury, based on the diagnosis codes submitted.
- Occurs when diagnosis code doesn't support procedure code.
- Payer determines if service is appropriate for diagnosis.
- Requires accurate ICD-10-CM to justify CPT/HCPCS.
Memory trick: Medical Necessity: 'M' for Match, 'N' for Need. Does the diagnosis match the need for the service?