ANALYZE ELEMENT Coverage Determinations

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National and Local Coverage Determination ANALYSIS

The Validation engine checks each treatment code to see if it is included on the list of National or Local Coverage Determination codes that require medical necessity. If a treatment code is on the list:

-Your selected ICD (diagnosis codes) are evaluated to see if they justify medical necessity

-If so, the edit passes without comment

-If not, the user is taken to the list of approved medical necessity codes in order to either:

     select a diagnosis code that can be billed with the treatment code OR

     if the patient's diagnosis doesn't match the list, have the patient sign an ABN form

     (this allows you to bill the patient only if the form is signed before providing



The user always has the option to cancel or override validation prompts.




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