Medical Necessity

What are the auditors looking for?

• Authentication – signatures, dates/times –

who did what? (metadata?)

• Contradictions – between HPI and ROS,

exam elements

• Wording or grammatical errors/anomalies

• Medically impausible documentation

How to Document Medical Necessity

• Tell a story

• Don’t assume level of knowledge

• Don’t rely on diagnosis documentation alone

• Review any payor medical policies – and

document in their terms

For example, for trigger point injections:

“Patient reports 60% decrease in pain after

previous injections”

 

How to Document

 

• Reason for any services ordered – labs, EKGs,

Xrays, other diagnostic studies –

 

CMS Documentation Guidelines:

“If not documented, the rationale for ordering

diagnostic and other ancillary services should

be easily inferred.”