Key Documentation Tips for ER Physicians to Prevent Medical Necessity Denials

by | Published on Jun 6, 2017 | Medical Coding

Medical Necessity Denials
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Documentation plays a key role in communicating to third-party payers that the evaluation and treatment services provided were medically necessary. While emergency room (ER) physicians should know that there are specific guidelines must be followed in medical documentation in order to qualify for the requested level of payment, a lot depends on clinical judgment too. Medical billing and coding companies can ensure accuracy in coding and claims processing only if the documentation captures the actual severity of illness and intensity of services provided. Demonstrating medical necessity is an indispensable element of justifying reimbursement in value-based care and preventing medical necessity denials.

A medical billing company can code and bill for a medical service only based upon what the provider has included in the medical documentation, assuming that the documented service was actually performed based on the necessity and suitability for a particular patient. Therefore, from the billing perspective, medical documentation justifies the medical service provided during the patient encounter. The basic rule is that “If it’s not documented, it never happened.”

Payers carefully review claims and supporting documentation to decide whether to pay or not. Medical necessity denials occur due to one of the following reasons:

  • The service was not medically necessary
  • The physician did not give enough evidence in the clinical documentation for the reviewer to identify the medical necessity

Documentation requirements vary by practice setting and by payer. To prevent medical necessity denials, the ER physician should:

  • Specify that the patient is in the correct status (admission or observation)
  • Put the patient in the right setting (general medical floor or intensive care unit)
  • Support medical necessity of testing in the documentation

Here are some key documentation tips for ER physicians:

Documentation in the history and physical (H&P) must support the severity of the patient’s signs and symptoms. Suppose a patient comes in with a compliant of chest pain, but the physical exam reveals severe gangrene in the left foot for which he is admitted. In this case, the list of diagnoses should include a note pertaining to the chest pain – which could be precordial catch syndrome (PCS) or a sign/symptom of chest pain with the exact location specified. The H&P must justify the patient’s risk of mortality and the possibility of an untoward event. The H&P should have: the chief complaint, associated signs and symptoms, and history of present illness (HPI).
In an article in icd10monitor, an ER physician offers the following valuable documentation tips to support medical necessity:

Ensure documentation to support the level of care: The provider should specify what the patient’s current needs are that require hospital-level care. The risk of not admitting the patient should be mentioned. Clinical judgment may supersede the established guidelines and in this case, the physician should explain why the patient with these acute/chronic conditions, specific symptoms, and particular social, medical, and family history details needs a different approach or status or setting than that suggested by the published criteria.

Document daily: Physicians should refrain from copy-pasting the medical decision-making assessment and plan. They should document the patient’s current status daily and explain why they are being provided the treatment.

Avoid contradictions/inconsistencies: Carrying forward information in the electronic record without careful review can lead to contradictions in a patient’s chief complaint documentation or history of present illness. Also, if the patient’s condition is described as “stable,” admission to the ICU is not warranted. Comments such as “patient is without complaints” should also be avoided if the patient is hospitalized. In this case, a better choice is: “although improved, still with…”

Use the most accurate ICD-10 code: ICD-10 requires coding to the highest level of specificity, making it critical that the details provided in the medical record are accurate and precise. To ensure that the medical coding company can provide the most precise codes risk-adjust for methodologies such as DRGs, HCCs, physicians should specify, severity, specificity, laterality, and linkage. This will provide a true picture of the patient’s condition.

Conduct documentation audits: Conducting audits can improve can enhance coding and clinical documentation accuracy.

Getting claims paid requires teamwork. Physicians, coders, and billers must work as a team to ensure to meet all the requirements for proper claims submission and payment. Medicare has guidelines for local coverage determinations (LCDs) and national coverage determinations (NCDs) Third-party payers also have specific coverage rules as to what they consider medically necessary or have riders and exclusions for specific procedures. Familiarity with these rules is crucial for accurate claim submission. Outsourcing medical billing and coding to a reliable service provider is the ideal option to ensure error-free documentation to support medical necessity, ensure precise coding, prevent denials, and receive optimal reimbursement.

Natalie Tornese

Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.

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