Practice Management Alert

Question: What are the core tenets of documenting and illustrating medical necessity?

Minnesota Subscriber

Answer: Medical necessity means proving that the services rendered were in line with accepted standards of care as well as being safe and effective. Although several organizations, including the American College of Medical Quality, the AMA, and Medicare Administrative Contractors (MACs) have slightly differing definitions, all of the organizations emphasize the aforementioned criteria.

“For medical necessity, you need to make sure that your documentation is accurate. You want to make sure you document the reason for the visit,” said Stephanie Stinchcomb Storck, CPC, CPMA, CUC, CCS-P, in the AAPC HEALTHCON 2024 panel “Unveiling the Insights: “In the Medical Record.”

It’s also crucial to show why a clinician may have ordered any tests, how the patient or caregiver has managed chronic conditions, and the clinician’s impression and assessment of the patient’s condition status and treatment plan, she said.

“You want to document the initiation or changes in the treatment plans, and also include any instructions or postcare for medications or therapies,” she said.

Bottom line: Establishing medical necessity means illustrating, with evidence, the pertinent reason(s) a patient seeks care.