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Thread: Medical Necessity

  1. #1
    Join Date
    Apr 2007
    Hawaii Chapter

    Default Medical Necessity

    AAPC: Back to School
    Our center is concerned about our E/M levels, medical necessity in particular. As long as I can remember, medical necessity was derived from calculation of the MDM, but we have an extraordinarily low level of 3s vs. 2s and 4s for our ED visits. So we do not have that nice bell curve, but rather something that emulates an "M" (with the peaks at levels 2 and 4). Since then I have been trying to find something that states not only do we calculate medical necessity using CMS' audit tool to calculate the MDM, but we need to follow CPT/AMA guidelines that also state the severity of the presenting problem need be of a certain severity before selecting a level of service as well.
    Does anyone have any input; agree, disagree?
    As a coder it is fairly hard to say this certain problem is of moderate severity vs. that problem is high severity...unless the provider provide the coder with the severity. I think this severity should be part of the plan vs. part of HPI's severity as the HPI is the what the patient is feeling verses the provider's opinion.
    I appreciate any help on this difficult subject!
    Leona Kiamahoe CPC, CPC-H, CPC-P

  2. #2
    Join Date
    Apr 2007
    Milwaukee WI

    Default How physicians think

    I attended a seminar last month where one of the presenters is a physician who was responsible for developing the practice's educational tools for teaching physicians documentation guidelines for compliance.

    The presenter started by getting a good education in coding, and noted that the way we coders think is not the way the physician thinks.

    We get out our audit tool and start at the beginning - with the history. But physicians see a patient and start their thinking process with the presenting problem.

    So the presenter developed a "Simplified Table of Risk" which used ONLY the presenting problem section to identify the level of risk - Minimal, Low, Moderate or High. This made sense to physicians because they understood right away that if a patient presents with a runny nose and congestion they'll want to look at XYZ in terms of taking a history and examining the patient -vs.- a patient who presents with pneumonia where the physician will want to look at ABC in terms of taking a history and performing the exam.

    The presenter further educated physicians on how the bullet points of history and exam tied to the "RISK" ...

    The end result (it took some time for every physician in the practice to internalize this information) was documentation that was much more compliant and reflective of the level of service chosen.

    A lot of the group in the seminar immediately questioned why they would leave out prescription meds in determining level of risk. The presenter emphasized that the simplified table was an educational tool - not an auditing tool. When auditing credit was given as per the auditing tool and used all the table of risk.

    But the outcome after about a year, was that the audit showed a much higher level of compliance.

    Hope that helps in thinking about these issues.

    F Tessa Bartels, CPC, CPC-E/M

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