Ensuring your documentation meets medical necessity standards

In 2003, the Centers for Medicare & Medicaid Services (CMS) made a change within the Claims Processing Manual regarding the selection of the evaluation and management (E&M) level of service to be effective in 2004. This change made the need, reason, or extensiveness of the encounter the dominant factor, as opposed to the volume of documentation – otherwise known as medical necessity. While that was 15 years ago, audits seem to be catching up with this modification, and enforcement is at its maximum extent.

While this seems like a more clinical approach to documentation requirements, which providers would be in favor of, the problem has become the language of the content. CMS has stated that the provider is tasked with “painting a portrait” of the patient through the documentation of each encounter to demonstrate this medical necessity. Therefore, the documentation must communicate effectively the need, reason, and extensiveness of each encounter.

Providers often do this, but the language used to communicate it is clinical in its approach, as one provider to another – as you would think it should be. But remember, who audits documentation on the pro-fee side, nine times out of 10? Non-clinicians. Auditors are taught that they are not allowed to assume or interpret, and therefore, over time, documentation expectations have morphed from clinically driven documentation to documentation that passes a non-clinical review.

But herein lies the problem, and the common disagreement between provider and auditor.

You see, as earlier stated, providers are taught that documentation is communication from one provider to another, which makes perfect sense. As a matter of fact, if we look at the introduction to the 1995 and 1997 Documentation Guidelines, they start off by listing what documentation is and why is it important. In this portion of the guidelines, we find elements like chronicling the patient’s health history, continuity of care, and even one portion (out of about nine) that has to do with claims adjudication.

But quite frankly, in 2019, documentation is more about a provider logging entry of every single thing it did for a patient, in order to meet insurance criteria for claim payment. In other words (get ready for a dose of reality), documentation is a provider’s defense, period. It should defend why tests, diagnostics, or procedures were performed for each patient encounter, not to mention why the level of service billed applied. If a code descriptor reads “encounter performed while the patient was standing on their head,” what do we expect to see in the documentation? But sometimes, we fail to remember that we must literally support code descriptors.

So, at the end of the day, our providers should document an encounter to get paid and to communicate with another provider what they did. And they are expected to also communicate this in non-clinical terms, as most commonly, non-clinicians are the ones reviewing documentation. When have providers ever been taught this in med school?

Many providers, upon hearing this for the first time, are rather shell-shocked and do not understand, as they were taught to document from one clinician to another. Truthfully, that makes the most sense, but when have carrier and CMS guidelines ever made sense? Hence the reason for the title of this article.

After going to a large health system and conducting provider-level education, I received a panicked call from one of their in-house auditors. They had an oncologist who had adopted a new style of documentation, and quite frankly, I would call it the “bad scale.” How many “bads” he documented in the plan of care implied how complex the patient was for that date of service. So we were reading notes that read “my patient was bad, they were very, very bad.”

Look, I get the sarcasm in the documentation – we ask for “lay talk” – and well, he certainly gave us that. However, the intent was never that our providers would rate patients on a “very, very bad” system.

You see, there is much more scrutiny on providers in healthcare than in other industries that are not as regulated. Think about an attorney. While the attorney must speak to a court in accordance with the letter of law, in a judicial manner, their audience is also a jury, full of individuals that more than likely have no training in law outside of what they hear on television (and we don’t hear them saying things like “my client is innocent, very, very innocent.” Attorneys have the ability to speak two languages, one a technical language that the common layperson may not process without considerable thought and research (and commonly, this conversation is with another attorney, a court, a judge, etc.)This language is much like how our providers communicate from one clinician to another. However, when an attorney walks into a court and faces a jury, they must now present a case in language that needs no translation, no research, and no large scholarly boundaries to cross. Today, most providers speak a non-clinical language to their patients but document with a clinical approach, which, based on the above law analogy, makes sense, but remember: a provider documents for the insurance carrier for reimbursement. The attorney is paid cash by someone who retains them, as this is not regulated by a system like insurance or the government, so direct documentation is necessary to ensure appropriate reimbursement for the service(s) provided.

As coders and auditors, it is our function to support providers in efforts to create compliant documentation, coding, and billing, and this applies whether you are a carrier coder/auditor or internal. As a carrier, you are tasked with creating policies and guidelines (that should be published as a matter of PAR provider access) for which you will hold them accountable. As an internal coder/auditor, you are the actual gatekeeper of compliance. You are responsible for ensuring, either retrospectively or prospectively, that services billed are appropriate. Therefore, all coders/auditors are responsible for letting providers know the following:

    1. Expectations: Rules and guidelines of what is expected for services billed
    2. Deficiencies: Findings of documentation review in which services were not as clearly supported as required
    3. Proficiencies: Findings of documentation reviews in which documentation clearly supported the services
    4. Feedback: Corrective measures needed

Providers can continue to document their encounters in a clinical approach, just as in a legal briefing; however, they do need to be tasked with providing a 1-2-sentence layperson’s description of the service, just as in a jury summation.

As we look to the future of E&M outpatient/office guidelines changing, be careful to remember that it is the scoring process that is changing, not the documentation process. And there have been no changes, as of yet, to the impact medical necessity will have to the overall selection of your E&M level of service.

Therefore, start working toward ensuring your documentation meets medical necessity standards for today, tomorrow, and 2021.


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