Another way to look at medical necessity vs medical decision making is:
The medical necessity for performing the key components of history and exam are determined by the nature of the presenting problem, the patient's own personal history and the clinical judgment of the provider. The medical decision making, that is the diagnostics ordered, the assessment and the plan are formulated as a result of the nature of the presenting problem, the patient's past medical history, and the history and exam performed at that visit. Medical decision-making is the outcome of the visit and is not a substitute for medical necessity. If CMS had wanted medical decision making to be that substitute then the Medicare Claims Processing Manual would read, “medical decision-making is the overarching criterion in selecting an E/M service” instead of medical necessity. If CMS had wanted medical decision making to be a substitute for medical necessity than either medical decision-making would be required in determining the code or all codes would require all three components.
Physicians do need to use their electronic health records in a way that more clearly documents what happened at the visit. In most cases that means document what would have been dictated.