Medical Necessity Germane & Inherent to Medicine

Medical Necessity is assuming even more importance as the crux of medicine with the increased focus upon the healthcare delivery model transitioning from Fee-for-Service to Fee-for-Value. An inherent challenge in decisions of medical necessity is the inherent subjectiveness of determining whether the care provided meets medical necessity. Determinations of medical necessity are fluid, with different requirements for different third-party payers. The concept of medical necessity spans the entire spectrum of healthcare whether Medicare has Local Coverage Determinations, National Coverage Determinations or other third-party payers have policy bulletins covering specific services. Medical necessity is materially fundamental to medicine, integral to the revenue cycle and greatly impacts the financial welfare of the patient. A common theme of medical necessity is clinical documentation, to what extent does the provider’s documentation convincingly outline the need for care ordered and/or provided. While there are other requirements associated with establishment of medical necessity such as frequency limitations particular to a service such as screening colonoscopies and screening mammograms, solid clinical documentation serves as the hallmark and drives determination of medical necessity.

Importance of Clinical Documentation

Clinical documentation improvement specialists play a vitally crucial role in assisting providers to establish medical necessity for services ordered and/or rendered on behalf of the patient. I am of the belief that rather than refer to the profession as Clinical Documentation Improvement Specialists, we should think of ourselves as Clinical Documentation Patient Advocates. If you take a close look at our ultimate role in documentation that accurately and completely communicates the care provided and/or ordered, we are collaborating with physicians to insure the patient receives optimal quality focused patient centered cost effective and efficient care supported by documentation reflective of the physician’s clinical judgment, medical decision making and thought processes.

Medical necessity requires clear and concise documentation of the following:

• Right Care
• Right Time
• Right Reason
• Right Venue
• Right Clinical Judgment, Medical Decision Making and Thought Processes
• Right Plan of Care
• Right Clinical Documentation.

CDI can best approach the important role of advocating for, promoting and achieving effective clinical documentation that clearly and unequivocally establishes medical necessity by collaborating with the physician to clearly describe show and tell the patient story in his/her documentation to the extent the patient can be found in the story. How does the CDI specialist tackle physician documentation to best express medical necessity? Quite simply, by focusing upon understanding and embracing the concept of clinical judgment and incorporating into our knowledge base as an integral component of regular chart review. Clinical judgment can be defined as the physician’s assessment of a patient’s particular clinical scenario and the initiation of action congruent with the assessment. Let’s break this down into understandable pieces that can be assimilated into the practice of CDI chart review.

Clinical judgment can be broken down into the following elements:

• Chief complaint
• History of present illness with an emphasis upon “present,” striving for performing and recording of at least four elements of a HPI
• Physical exam congruent with the patient’s presenting problem with focus upon abnormal findings
• Relevant Past Family Social History
• Discussion with relevance of abnormal lab values, radiology results and other available diagnostic tests results available
• Provisional and/or definitive acute diagnoses with appropriate clinical specificity and clinical rationale/thought processes documented
• Ability to trace back all acute definitive and/or provisional diagnoses to signs and symptoms as recorded in the History of Present Illness
• Plan of care congruent with the assessment- each physician order should be easily traced back to the recorded diagnosis-Don’t leave the reader hanging and relegated to assuming why treatment or workup is being performed.

Practically speaking medical necessity can be achieved through clear and complete documentation that addresses the following requirements:

• Number, acuity, severity and duration of problems addressed by physician
• Extent to which co morbidities impact complexity in management of acute clinical conditions
• Context of previous management of same conditions
• Number of body areas and organ systems the physician must contend with in clinical management
• Challenges and complexity of arriving at a diagnosis (es) and development of a reasonable management action plan

Getting Started

CDI as a profession can start in incorporating the important concept of medical necessity into our efforts at improving and enhancing documentation that captures by first recognizing it is within our scope of practice. Establishment of medical necessity is paramount to documentation improvement and factors into our current role of clinical documentation improvement specialists. I encourage all CDI specialists to expand their horizons and thought processes moving forward and use the above information I have outlined on key components of medical necessity in assessing the quality of the documentation in the establishment of medical necessity. The ultimate question one should be asking in reviewing the H & P is if there is a clear picture of patient acuity beginning with the chief complaint and History of Present Illness.