10 Documentation and Coding Principles to Demonstrate Medical Necessity
When preparing medical documentation and coding medical conditions, keep these 10 principles in mind to demonstrate medical necessity for services reported:
- List the principal diagnosis, condition, problem, or other reason for the medical service or procedure.
- Be specific when describing the patient’s condition, illness, or disease.
- Distinguish between acute and chronic conditions, when appropriate.
- Identify the acute condition of an emergency situation (e.g., coma, hemorrhage, etc.).
- Identify chronic complaints, or secondary diagnoses, only when treatment is provided or when they affect the overall management of the patient’s care.
- Identify how injuries occur.
- Assign diagnosis codes to the highest documented level of specificity.
- For office and/or outpatient services, never use a “rule-out” statement (a suspected but not confirmed diagnosis). If a definitive diagnosis is not determined, report symptoms and/or signs, instead.
- All facts must be substantiated by the patient’s medical record, and that record must be available for review upon payer request.
- When reporting a patient encounter, select codes that best represent the diagnoses addressed during that visit.