Codapedia is now a division of Find-A-Code

When Medical Necessity and Medical Decision Making Don't Match

August 3rd, 2018 - BC Advantage
Categories:   Evaluation & Management (E/M)   CPT® Coding   Audits/Auditing  
0 Votes - Sign in to vote or comment.

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.

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

HHS Proposes Significant Changes to Patient Access Rules
February 11th, 2019 - Wyn Staheli, Director of Research
In a significant announcement on February 11, 2019, HHS proposed new rules aimed at improving interoperability of electronic health information. This announcement was made in support of the MyHealthEData initiative which was announced by the Trump administration on March 6, 2018. The goal of that initiative was to break down ...
Charging Missed Appointment Fees for Medicare Patients
February 7th, 2019 - Wyn Staheli, Director of Research
Some providers mistakenly think that they cannot bill a missed appointment fee for Medicare beneficiaries. You can, but Medicare has specific rules that must be followed. These rules are outlined in the Medicare Claims Policy Manual, Chapter 1, Section 30.3.13. You must have an official “Missed Appointment Policy” which is ...
Q/A: Do Digital X-rays Have Their Own Codes?
February 7th, 2019 - Wyn Staheli, Director of Research
Question Are you aware if digital x-ray of the spine requires a different code than plain x-ray? If so, where can I find the information specific to digital x-ray codes? Answer There are no separate codes for digital x-rays. However, there may be modifiers that are required to be submitted with the usual ...
Clinical Staff vs Healthcare Professional
February 5th, 2019 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
State scope of practice laws and regulations will help determine who is considered Clinical staff and Other qualified Health Care professionals.  Physician or other qualified healthcare professionals:  Must have a State license, education training showing qualifications as well as facility privileges.  Examples of Qualified Healthcare professionals: (NOTE: this list is not all-inclusive, please refer to your payer ...
BC Advantage Now Offering Q-Pro CEUs!
February 5th, 2019 - Find-A-Code
We are excited to announce BC Advantage is now offering Q-Pro CEUs! It is now even easier to get your QPro CEUs and stay current with BC Advantage: offering news, CEUs, webinars and more. BC Advantage is the largest independent resource provider in the industry for Medical Coders, Medical Billers,...
Attestations Teaching Physicians vs Split Shared Visits
February 1st, 2019 - BC Advantage
Physicians often use the term "attestation" to refer to any kind of statement they insert into a progress note for an encounter involving work by a resident, non-physician practitioner (NPP), or scribe. However, for compliance and documentation purposes, "attestation" has a specific meaning and there are distinct requirements for what ...
Q/A: Can I Bill a Review of X-Rays?
February 1st, 2019 - Wyn Staheli, Director of Research & Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT
It is not unusual for a healthcare provider to review x-rays taken and professionally read by another entity. Questions arise regarding how to bill this second review. It is essential to keep in mind that the global (complete) service of taking an x-ray is composed of both a professional and ...



About Codapedia & Find-A-Code Contact Us Terms of Use Privacy Policy Advertise with Us

Codapedia™/Find-A-Code™ - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain) - Fax (801) 770-4428

Copyright © 2009-2019 Find A Code, LLC - CPT® copyright American Medical Association