Guided Notes

Medical Necessity, NCCI Edits & ABNs

Why payers deny correctly coded claims — linking diagnoses to procedures, NCCI procedure-to-procedure edits and MUEs, LCDs/NCDs, and the Advance Beneficiary Notice.

Medical necessity

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A payer pays for a service only if it was reasonable and necessary for the patient's diagnosis. On the claim, each procedure line is 'pointed' to the diagnosis that justifies it.

Example: a chest X-ray pointed to 'cough and fever' — supported. The same X-ray pointed to 'ankle sprain' — likely denied as not medically necessary (CARC 50).

Coders don't invent diagnoses to justify services — they code what is documented, and flag mismatches to the provider.

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