Medicare and other health insurance payers commonly use the term “medical necessity”. The term implies the need to “justify” the choice of treatment by linking the service (CPT code) to the diagnosis, symptom, or complaint (ICD code). Failure to appropriately link the diagnosis to the service is a common reason for insurance denials. Appropriately linking the ICD code to the CPT code requires that only the reason (ICD) for the service (CPT) be associated with the CPT code.
For example, if you performed both an epidural steroid injection for low back pain and a left shoulder injection for primary osteoarthritis, you would only associate the back pain with the ESI and only the osteoarthritis with the shoulder injection. Payers use only the first linked diagnosis to determine coverage. Therefore, if you listed both ICDs with both procedures, it is likely that one of the procedures will be…
