Certified Clinical Medical Assistant CCMA Practice Test

What indicates the medical necessity of a procedure on the CMS-1500 claim form?

1. Procedure code

2. Provider's signature

3. Diagnosis code

4. Date of service

The correct answer is: Diagnosis code

The correct answer is the diagnosis code. This code provides essential information about the patient's condition or reason for seeking medical care, which is critical for demonstrating the medical necessity of a procedure. When a healthcare provider submits a claim, the diagnosis code is used to justify the services rendered. Insurers review these codes to ensure that the procedure aligns with the patient's diagnosis and is deemed necessary for treatment. The other options do not determine medical necessity in the same way. While the procedure code marks the specific services provided, it does not convey the justification for them. The provider's signature is essential for validating the claim but does not indicate why the procedure was necessary. Lastly, the date of service is important for record-keeping and billing timelines but does not address the necessity of the procedure itself in the context of the patient's medical condition. The diagnosis code is the vital component that connects the procedure to the patient's needs.