Stay Compliant: Documentation Must Support Medical Necessity

Closeup of doctor writing on chartBy Kim Reid, CPC, CPMA, CPC-I, CEMC

Defining the level of care a patient requires while proving medical necessity can be a chore. Here are some tips to help you assure compliance.

Evaluation and Management – CEMC

Medical necessity determines the type and level of service that should be billed. Because the evaluation and management (E/M) guidelines are complex and subjective, providers may rely on a template so notes are documented the same way each time they see a patient. The problem is that not all patients require the same level of care at every visit. Only services that are required to treat the patient’s problem that day should be provided.

A child who comes in with a cough and a runny nose, without a fever or other symptoms, may be diagnosed with an upper respiratory infection. If that same child came in with a croupy cough with a fever and was having a hard time with shortness of breath, the physician may be concerned that could be pneumonia. This probably would cause the physician to order a chest X-ray, as well as to perform some lab tests. By documenting the thought process or concerns for the second example, it is clear there is a greater risk to the patient’s well being if the problem is not treated.

Much of the work physicians do is not documented in their note because they feel that another clinician looking at the note would understand things that are “inferred.” But many different people, not just clinicians, review the note. Often, coders do not have clinical backgrounds; details must be clear to the non-clinical person, as well. Providers often feel that this takes away from their notes. Keep in mind that medical documentation serves many purposes and one of them is to tell the story clearly of what is happening with the patient, and why the provider performed the work they did in each specific instance.

Regularly perform documentation audits to check medical necessity.  Complete documentation shows payers the physician knows what is happening clinically with the patient.


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6 Responses to “Stay Compliant: Documentation Must Support Medical Necessity”

  1. Julia, CPC says:

    Medical Decision Making should drive the visit – I think this point is lost when trying to just count ‘bullets’ in order to justify a visit. Thank you for bringing up this issue.

  2. Stephen Levinson says:

    Critically important concept. The medical necessity sets the upper limit of code that is warranted, regardless of the amount of care. It is even more valuable to utilize the correlation of medical necessity with the level of care than must be performed and documented to meet physicians’ own standard of care. This information is detailed in CPT in two locations: 1) In the E/M section, the Nature of the Presenting Problem (NPP) is the E/M system’s measure of medical necessity; this is explained in greater detail in Appendix C of CPT which provides Clinical Examples from physicians’ own specialty societies. These illustrate and explain how medical necessity indicates the appropriate level of care that is “medically indicated.” Physicians can assess the NPP at the same time they compile a preliminary differential diagnosis, which is after completing a comprehensive medical history (in an established patient visit, this can include an update for the PFSH and ROS, per Documentation Guidelines). Julia’s observation that MDM should drive the visit is a step in the right direction, but NPP is far more powerful and reliable. In particular, for those who employ the non-sanctioned and partially non-compliant “Marshfield Tool” for MDM, non-compliantly high levels of MDM are readily achieved for low severity illness (and only low level MDM may result for follow-up of a single life threatening illness). Thank you again for shining a spotlight on this topic.

  3. Chris Denis, RCP, CPC, CUC says:

    Kim and Steven,

    Bravo for reminding us about the thought process being documented to support medical necessity- A core fundamental that can get lost when providing patient care. Also, forgotten by healthcare providers are the many channels a healthcare record can travel through that is not comprised by just clinician’s.

    Thanks Steven for your insight on NPP and I totally agree that is a vitally critical point that should be considered the “lens” that captures the perfect snapshot. Maybe medical documentation should be treated like fine photography? If more healthcare providers could for a moment realize that medical documentation is not meant to be a hassle nor just a means for reimbursement but rather a chronicle of a thought process and history of that patient.

    It is awesome that this topic was addressed in this forum!

  4. Karen Bartrom, CPC, CEDC, CEMC says:

    I have concerns about MDM being a driver of a visit. A patient returns to their oncologist for a 6 month follow-up – personal history of cancer. The oncologists tell me (and I believe them) that often it is medically necessary to take at least a detailed history and perform at least a detailed exam. In the end MDM may be low or even SF but a medically necessary 99214 was documented. It is important to remind insurance carriers, etc that MDM and medical necessity are different things.

  5. Lydia Chitwood, CPC says:

    Even if the MDM is high, e.g., a surgeon sees a new patient in consult and has determined that open heart surgery must be performed, if the HPI/ROS/PFSH documentation doesn’t qualify as comprehensive, or the exam doesn’t qualify as comprehensive, then your level of service is lower since you must have 3 out of 3 components to code high complexity.

    Isn’t it difficult to say that any one of the components drive the level of service when, depending on medical necessity and documentation, any one of those components may not allow a higher code? (for new patients)

  6. Connie Eckenrodt. RHIT, CHCA, CHC says:

    Karen, you make a good point. However, documentation is key. It is not enough for the oncologists to tell you “that often it is medically necessary to take at least a detailed history and perform at least a detailed exam” on a follow-up visit. As Kim suggests in her article, the patient’s encounter story needs to be documented, clearly told so that it may be understood by a wide variety of readers, to include clinicians and non-clinicians alike. If the oncologist felt it was necessary to perform a higher level of history and/or exam than may have been borne out by the nature of the presenting problem, the medical record documentation should reflect the reasoning, the medical necessity, and thereby, the MDM.

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