Don’t get caught in coding, the clinical matters too

Compliance officers should be careful to remember the clinical side of compliance, as well as the legal components, according to a webinar titled, “The Medical in Medical Necessity,” presented by CJ Wolf, Senior Compliance Executive at Healthicity, and sponsored by the Health Care Compliance Association (HCCA) Wolf reminded compliance officers that just because you have proper medical documentation for a service does not mean the service was provided with medical necessity.

Medically unnecessary

Wolf walked through examples of instances where Medicare or Medicaid fraud cases resulted from allegations that providers billed for medically unnecessary procedures. He used specific clinical information to describe how allegations led to fraud settlements or convictions. He pointed to examples from cardiology where physicians allegedly billed for unnecessary stress tests, ultrasounds, tests without prior examinations, peripheral interventions, and groin artery tests. More generally, Wolf noted, medical necessity may turn on specific local coverage determinations (LCDs) or requirements from a Medicare administrative contractor (MAC). As an example of this, he described a scenario where a MAC required that a provider try a conservative treatment option before a more costly treatment method could become medically necessary.


In the event that a physician is allegedly providing unnecessary medical services, compliance officers can rely on information from organizations like the Society for Vascular Surgery, the American College of Cardiology, and the American Society of Echocardiography to determine the appropriateness of services. Such organizations, in the case of cardiac services, can provide an overview of which interventions are necessary for particular situations, including those that are permissible first line treatments. Additionally, Wolf noted that the medical necessity of services is something which reaches beyond compliance and the anecdotes of providers. For example, he pointed to clinical studies published in the Journal of the American Medical Association (JAMA) regarding the frequency of appropriate or inappropriate medical interventions.