EDITOR’S NOTE: This is the last article of a two-part series on the algorithms of medical necessity.


As compliance professionals, the conversation about qualifying medical necessity or medical decision-making probably has surfaced at one time or another during education with providers, coders or auditors.  As discussed in the first article of this two-part series, these phrases often  are used interchangeably and have caused all of us to think about how to best manage and monitor when it comes to documentation and coding.


Active Communication


To start the process of managing medical decision-making among physicians and auditors (or coders), communication is a key component that many organizations have failed to recognize.  As hospitals and health systems transition through business models to employ providers, the dynamics of the central billing office (CBO) have become indispensible as they pertain to facilitating the consolidation of billing, coding and auditing staffs. As a part of this model, personnel sometimes are moved to a different location, where they may not have the luxury of direct communication with their providers. Furthermore, CBO models also may have their own chains of command to provide feedback if errors occur within the revenue cycle. Without this regular correspondence between providers and coders, the notion of one party assuming what the other is thinking (or documenting) may not represent the best support system when appealing a CMS audit.


Understand Your Provider Specialty


So consider that your compliance department now is scheduling regular meetings with providers. Aside from feedback from educational audits or the input about new coding rules, what can I learn from my physician? Let’s go back to the first article and the first part of the medical decision-making algorithm: the number of diagnoses or problems. Remember, within the industry this is a fairly standard template for indicating what type of decision was rendered for a particular office visit.


Again, there are four choices, but let’s focus on two of them: “self-limiting problem” versus “new problem.” This can look very different depending on specialty or sometimes your provider. To better audit or code for your specific provider, take their top 20 diagnoses and have a conversation about how each is managed with regard to history, exam, time and overall ease of treatment.  This process can provide insight that the auditor can use to instruct other staff or providers, and this potentially can bolster one’s case in the appeal process for a payer audit.


Monitor Performance and EHR Data



As with almost all compliance processes, if you can’t measure it, you can’t manage it.  We measure everything when it comes to new and existing processes. Let’s redirect the focus back to medical necessity. Consider that the compliance department and providers are communicating regularly and have developed internal tools to understand the process of contrasting diagnoses that are more straightforward to those that are more significant.  The health system recently transitioned from a pure dictation system to a full electronic health record.  The transition team has provided templates and pre-populated areas where providers can click and drop in notes.  Documentation is thought to be more complete than ever. Think again, though: what may be dropping in may not be the intent of what’s coming out.


For providers, this is truly an “ah ha” moment, and unfortunately, CMS has caught on as well. If you can do two things in the first few months of optimization in terms of electronic health records, do the following: a) turn off the encoder and b) print your finalized notes for your providers to “self-audit” and test note logic. If there is a common glitch in electronic health records, it’s the pre-populating of active problems to current assessment.


If the provider did not cover the problem in the daily visit, the diagnosis should not be included on the claim form or within the assessment portion of the note. Always advise providers to view notes before authentication is completed to ensure that all information is correct.


In the coming months, a new series of articles will focus on electronic health record errors and how to identify them before the government finds them first.


About the Author


Jana B. Gill, MA, CPC, is a product engineer and developer of Regulatory and Reimbursement software suites for Wolters Kluwer. Jana also is the principal of Gill Compliance Solutions, LLC which specializes in physician compliance, developing internal auditing programs, government appeals (RAC/CERT), coding risk assessments, due diligence for physician/hospital integrations and revenue analyses of hospitalist services.


Contact the Author




To comment on this article please go to editor@racmonitor.com


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