Medical necessity in E&M remember severity, acuity, medical problems
Medicare and private health plans, with very few exceptions, will pay only for medically reasonable and necessary services. These payer?s will determine what is ?medically reasonable and necessary? separately from determining the physician performed the work reported. The documentation, being open to interpretation by payers, must support the Evaluation & Management (E&M) services coded for, that the work described is appropriate and supports for the patient?s needs and condition (e.g., severity, acuity, medical problems) or the payer may reject the claim due to medical necessity.
A coder should be well practiced in the analysis of the levels of service compared to the documented diagnoses, due to the repetitive nature of documentation review in coding. And as such, they are often able to identify possible irregularities and cases when Medical Necessity might be questioned.
A SOAP note is a documentation method employed by healthcare providers to create a patient?s chart.
There are four parts to a coding SOAP note:
- Subjective
- Objective
- Assessment
- Plan
These all relate to the patient?s current condition in narrative form by the clinician. But, coding should not be considered equal to the clinical SOAP note.
- Subjective: Opinions
Medical Necessity is a clinically required action ? it is the reason for a service and validates the provision of service. It is open for interpretation by all parties involved.
- Objective: Facts
Medical Decision Making is a measurement of work. It is defined by the 1995 and 1997 Documentation Guidelines and the Marshfield Clinic audit tool. Due to these guidelines, a coder (or an EMR computer programmer for that matter) is able to calculate a technical level of service. Medical Decision Making is the mathematically formulated result of all documented components of the physician?s service, whether medically needed or not. It is the data driven outcome of a patient visit and not a substitute for determining the appropriateness of the services rendered or the Medical Necessity.
- Assessment: Judgments
The best way to stay compliant with Medical Necessity related laws is to think of each element of the patient?s history and physical exam as a separate procedure that should be performed only if there is a clear medical reason to do so. This requires making a clinical judgement. A coder, while better educated than most non-clinicians, is not able to make that judgment with the certainty of a medical peer.
- Plan: Strategies
You have to have one! In an effort to bridge the gap between the clinical savvy of a documenting provider and a clinically untrained coder some coding administrators have exchanged the definition of Medical Necessity with the Medical Decision Making (MDM) component of E&M services. This mistake that often leaves money on the table or results in over-payments.
Coders must create a feedback loop that incorporates the clinical judgement of the E&M service provider. This is often accomplished by creating policies that can be used throughout the organization to ensure speed and consistency.
These should include:
- Guidelines for clinical conditions that demonstrate probable service levels
- Polices that protect against errors
- Policies to do the ethical thing
- Policies that can be understood and followed