When Medical Necessity and Medical Decision Making Don't Match

As coders and auditors, we are taught the documentation guidelines on how to determine medical decision making. However, Medicare is clear that medical necessity is what determines the overall payment. In order to know what to do when medical necessity and medical decision making do not line up, you must first look at how they are determined.

Determining Medical Necessity (MN)

Although there are great tools and resources to determine MDM, the documentation guidelines do not illuminate how to capture this elusive, yet critical element, for supporting the level of service. There are caveats, and exclusions, but nothing that says "x documentation equals Y medical necessity."

Even without these firm, easy, explicit guidance, as coders and auditors, we have all found that note, the note that has clear life threatening medical necessity, and codes out to low or moderate MDM. What is supposed to happen in these cases? First, we must look at how the medical necessity is created in the encounter.

The History of Present Illness (HPI)

When the patient is being queried on the how, when, what, etc., the provider is determining whether this condition is something that is critical, major or minor. For example, a patient presenting with a cough, this can be something that will resolve on its own (seasonal allergies) or could be a sign of respiratory failure.

Examination

This is the element in which the provider uses his or her own expertise to determine if they feel it is minor, or major based on the physical health of the patient.

Determining Medical Decision Making (MDM)

This is where the provider illuminates his or her thoughts, concerns, and determinations. In the perfect example, with explain where the patient is in the process, and what they intend to do to prevent progression. Just like with HPI, MDM can often be found throughout the encounter, not just at the usual designated spot.

NAMAS has created a tool that helps determine the level of medical necessity, for E/M Services, Inpatient Services and Emergency Room Services, to give a more clear guidance on how to capture the critical elements. In my opinion, when the medical necessity is higher than the MDM, and supported by the history and/or exam, I will always support the level of service that I feel lines up with it. If the documentation clearly supports a life threatening exacerbation of an existing problem, to where the patient is transported by ambulance to a hospital, this would be high medical necessity. Even though the MDM might only below for one established worsening chronic problem.

As coders and auditors, our job is to find these gaps, and not get weighed down by checking boxes on our resources.

This Week's Audit Tip Written By:

Omega Renne, CPC, CPCO, CPMA, CEMC, CIMC

Omega is a Compliance Consultant for our parent organization, DoctorsManagement.

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