Documentation Tip: Medical Necessity

Medical necessity is required not only for E/M services, but must be shown for every service provided to a patient. Medical necessity helps demonstrate the complexity of caring for a patient's condition and is crucial to ensure that the service is supported in case of audit.

With HER-generated documentation, we as auditors often find that while documentation requirements are satisfied, the medical necessity to support a selected level of service is not clearly shown, which can endanger the entire claim. Be sure to include in your documentation specific notes that demonstrate the complexity of care the patient required.

This is most effectively accomplished in the history and the plan of care. If you use an EHR to fill in the blanks, consider adding a free-text section to each of these areas to better capture the patient's condition. The history information should clearly identify the reason for the encounter and the symptoms the patient is having due to his or her complaint. This will help to show the severity of the patient according to the patient. The plan of care should capture the patient's severity according to the provider's assessment and analysis of the patient throughout the encounter.

The plan of care should reflect the provider's thought process in caring for the patient and should show the unique complexities that can arise with individual patients. Taking the time to have providers do this will ensure your claims contain iron-clad medical necessity documentation.

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