One of the major criteria used by Medicaid programs and commercial payers for determining coverage of services and procedures is medical necessity. The use of appropriate International Classification of Diseases, Ninth Revision, Clinical Modification codes supports the medical necessity of a service or procedure.

Current Procedural Terminology (CPT®) guidelines do not preclude the reporting of any procedure or service based on diagnoses. It is improper for payers to justify coverage of a reported CPT code based on reported diagnosis(es). However, the Centers for Medicare & Medicaid Services has established criteria for reporting certain diagnoses with certain services or procedures as published under the Medicare Coverage Database (MCD) and Local Coverage Determinations (LCDs). Many payers, including Medicaid programs, adopt the MCD and LCDs. Other payers may use their own criteria or other published software programs.

Practices must be aware of the criteria used by major payers and should appeal...

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