Medicare Archives

The Relationship Between Box 14 and Medical Necessity

A provider of service communicates important information about a patient’s episode of care by placing important information in Box 14 of the 1500 billing form. The date that is placed in this important field on the billing form communicates the first date of the current episode of care. This brief training will outline it’s importance…

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Proper Patient Case Management

The Case Management Picture Case management has its roots in the patient’s clinical presentation and the doctor’s training and expertise. Doctors have a fiduciary responsibility to evaluate patients and determine the whole clinical picture to the best of their ability. The patient evaluation process is quite linear. The doctor begins by gathering the patient’s history…

Medicare Decision Making Matrix

Download Support Tool This tool is one of the most useful and important tools in the KMC University Curriculum. Although designed for Medicare using Medicare terminology, the flowcharts apply to any type of third-party insured patient. An important question is posed as a patient presents to the office: “Is this patient currently in an active…

Active vs. Maintenance in Medicare

Recognize the Differences Between Active and Maintenance Care One of the most difficult concepts for providers to grasp is the fine line that exists between the necessity of active treatment and when the care would be deemed maintenance. This distinction is critically important because declaring a visit to be medically necessary, therefore billable to and…

Medical Necessity vs. Clinical Appropriateness

Clinically appropriate care is that recommended treatment that is within the doctor’s scope of practice and appropriate for the patient but may not meet the medical necessity guidelines of a third-party payer. Patients have every right to receive this type of care, but both provider and patient must be aware that it is likely paid…

Medicare’s Definition of Medical Necessity

Every payer has a definition of medical necessity and Medicare is no exception. Medicare Administrative Contractors (MACs) release a Local Coverage Determination (LCD) where they provide healthcare providers of all specialties their rules and definitions so they can determine if the care they are providing to their patients is payable. The following definitions pertaining to…