Ensuring your claims are approved often hinges on one critical factor: documenting medical necessity. This is especially true when ordering or performing Assess (Standard Battery Assessment). A lack of clear clinical rationale or mismatched codes can lead to costly denials and delays in care.
To help you stay out of the denial zone, here’s a quick and actionable guide:
1. Start with Diagnosis & Symptoms
Your first line of defense is a well-supported diagnosis. Insurance payers, including Medicare, require that testing is clinically justified by the patient’s condition. That means:
● Clearly link diagnoses and symptoms to the need for testing.
● Double-check ICD-10 coverage: Each payer may have specific policies outlining which diagnosis codes are considered medically necessary for neurocognitive testing. Use those as your guide.
Pro Tip: Most denials happen when the diagnosis doesn’t align with the payer’s accepted policy—even if the clinical rationale is sound.
2. When in Doubt, Follow Medicare’s Lead
While private payers can vary, many mirror Medicare Local Coverage Determinations (LCDs). If you’re unsure what a commercial payer will accept:
● Use Medicare guidelines as your baseline.
● Reference the applicable LCD to ensure that your documentation meets expectations.
This is particularly helpful when assessing cognitive functions such as memory, attention, processing speed, or executive function.
3. Prior Authorization (PA): Be Prepared
Some payers require prior authorization before approving claims. To avoid delays make sure to include:
● Diagnosis and presenting symptoms
● Tests requested (Trails A/B, Stroop, Digit Symbol Substitution, Immediate and Delayed Recognition)
● Clinical rationale – explain why the tests are necessary, not just what is being tested.
Having this documentation ready ahead of time can prevent back-and-forth with the payer and reduce the risk of denial.
4. Document, Document, Document
Good documentation is more than a formality—it’s your strongest tool to prove medical necessity. Your records should:
● Clearly state the reason for testing in your office notes or order form.
● Include relevant patient history and functional impairments.
● Show how the results will impact treatment planning.
Remember: payers want to see how testing contributes to actionable outcomes.
Denied for Medical Necessity? Don’t Panic
If you receive a denial, take a moment to walk through this checklist:
● Did you use the correct ICD-10 code per the payer’s policy?
● Are all tests performed listed in the chart note?
● Did you use the “copy documentation to clipboard” feature and paste the full report into the chart note?
● Is your clinical decision-making process clearly documented?
● Are recommendations and discussions of results noted in the chart?
If Something’s Missing:
Have the provider update the documentation to fill in any gaps and resubmit the corrected claim.
If Everything Checks Out:
Submit a reconsideration with full documentation, including your notes, rationale, and Assess report.
Need Help?
Avoiding denials and navigating the medical necessity maze isn’t easy—but you don’t have to go it alone.
Contact our billing team for support:
● Online: https://braincheck.com/contact-us/
● Live Agent Support: 888-690-0977
We’re here to help make your documentation airtight and get your claims approved the first time.
