Defining “Medical Necessity” for Documentation
All services provided to a patient who is receiving Medicare are subjected to Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This act demands that services meet a set criteria to be deemed “reasonable and necessary” — if your charts aren’t up to code, the physician or hospital risks losing that reimbursement for the diagnosis, treatment, or conditional improvement of a patient.
The Need to Know
In order to bill it, you have to show it.
Keeping charts up-to-date is crucial for reimbursement. You must chronicle the plan of care in order to justify any supplies, treatments, or tests used. All visits have reason, you just have to show why they’re there.
The patient’s chief complaints help establish medical necessity.
Knowing how to document a patient’s primary reason for the visit, as well as any comorbidities that may be uncovered during treatment, is not a simple process. The Medicare Learning Network® provides an easy-to-read Evaluation and Management (E/M) Services Guide that details general principals and common codes, as well as a reference section for both the 1995 and 1997 editions of the guidelines.
The Documentation Cheat-Sheet
No time for a deep-dive? Here are five points that the E+A experts rely on when scoring records for medical necessity:
• The patient’s problem (chief complaint)
• How long the patient has had the problem, along with the symptoms the patient is experiencing because of the problem
• How other organ systems are being affected by the chief complaint
• Historical concerns that could affect the treating of the problem
• Points of consideration on how the current problem may affect historical concerns of the patient
Granting a “Comprehensive History” Level
Determining whether the care provided was medically necessary is step one in any Review of Services. The Clinical Reviewers are required to examine all documentation in its entirety. If the charts clearly support that the patient is unable to provide a critical health history (due to unresponsiveness or inability to answer) and attempts were made to obtain the history from other sources, a comprehensive history level may be credited. Put simply, this credit approves the cost to run additional tests, perform exploratory procedures, and provide other services that will reveal the information needed to best treat the patient.
For More Information
Information related to the history component requirements are available in the 1995 and 1997 editions of the Documentation Guidelines for Evaluation and Management Services. Our staff is also highly skilled in specifics of Medical Necessity and are happy to provide education or a proactive review. Contact us online or call (855) 322-6337 to get started!