In the current healthcare climate, the issue of medical necessity documentation, or lack thereof, is one of the most common reasons for claim denials. For a service to be considered medically necessary (by a third-party payer), it must be considered a reasonable and necessary service to diagnose and/or treat a patient’s current and/or chronic medical condition.
A recent report released by the Centers for Disease Control and Prevention revealed that almost 70% of Americans are considered overweight or obese. This epidemic costs American healthcare systems approximately $190 billion per year in treatment of weight-related conditions.
CMS' Bundled Payments for Care Improvement Advanced model will qualify as an Advanced Alternative Payment Model under the Quality Payment Program and include outpatient episodes.
CMS' 340B FAQ reviews modifiers -JG (drug or biological acquired with 340B drug pricing program discount) and -TB (drug or biological acquired with 340B drug pricing program discount, reported for informational purposes) and requires 340B hospitals to report modifiers even on drugs that are not subject to the discount policy.
