Practice Management Alert

“Base medical necessity on documentation” sounds really easy and black and white, but what if the clinicians you work with have strong feelings about how medical necessity “should” work? The idea of coders or auditors or other staff members who don’t have clinical training determining the medical necessity can give some physicians pause.

It’s not that the provider rendered a service that was medically necessary for evaluation and management the patient, but rather that the documentation does not demonstrate the medical necessity for the level of service that’s billed, Fletcher says.

Tip: Make it part of your coding and billing audit process to look at the entirety of the document, Fletcher says. Look at the 360-degree view of the record, not just snippets. Medicare and other agencies are looking at everything that’s included on that date of service — so you should too.

“If something is included that wasn’t warranted or didn’t have medical necessity behind it, that’s also part of the discussion,” Fletcher says.

Assign Level of Service Carefully

Regardless of whether you’re familiar with the idea of a physician ordering tests unsupported by a patient’s clinical record, you can find out exactly how much of a problem this may be in your practice.

Conducting internal and external audits, at least annually, is a good way to achieve peace of mind, Fletcher notes.

When you audit for medical records, it’s to see if you can support the level of service, but you look at the ‘360-view’ and ask whether it supports the whole record, including the tests ordered, she says.

Don’t Get Lazy With Telehealth

“You can’t bill anything that isn’t medically indicated or within the rules for coverages,” Fletcher says. Don’t forget that this applies to telehealth too, where there are very specific rules.

The public health emergency (PHE) has loosened some of the restrictions on telehealth coding and billing, but the easing of rules really applies only to situations affected — at least tangentially — by COVID-19. The cutting of red tape surrounding telehealth would mostly affect services that were covered if the patient (who doesn’t have to have COVID or be tested for COVID) were to come into the office. This also applies to nonphysician providers (NPPs) whose telehealth services can be reimbursed under certain PHE-specific rules.

However, make sure you know and are following the guidelines as specified by the Centers for Medicare & Medicaid Services (CMS). Be thorough in your auditing, because regulatory agencies are looking out for pandemic-related fraud and are now stepping up enforcement.