General Question for the Week of February 5, 2018

General Compliance Question of the Week


What is the difference between medical necessity and medical decision-making?


In a February 1, 2018 RACmonitor article, David Glaser, Esq., answered this question as follows: “Medical necessity is the idea that insurance won’t pay for a service a patient doesn’t need. That’s a very basic and reasonable principle in insurance. Medical decision-making is an attempt to create a formula to quantify the amount of effort a medical professional expends on evaluating a patient. The methodology for evaluating medical decision-making is contained both in the CPT® book and in the Centers for Medicare & Medicaid Services (CMS) E&M documentation guidelines.”

For the article, go to

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Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.