Understanding documentation and medical necessity is critical to avoid denied claims and overpayment recovery. According to the CMS Medicare Claims Processing Manual:
Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported.
Therefore, you must make an effort to document enough, not more. This means you should clearly document enough information to support the principal and contributing diagnoses. And no longer is listing a condition on a problem list enough.
To help you with your documentation efforts, we have asked one of Healthcare Compliance Pros Coding Auditors to provide some tips. Here are her recommendations:
- Documentation should support medical decision making; medical decision making drives documentation and coding.
- Specificity – you should document as specifically as possible when describing your patient’s condition.
- Co-morbidities – make the link between co-morbidities and the condition you are seeing for optimum medical decision making.
- Analyze your billing /coding process to ensure accurate information is being submitted to reduce risks that that occur as result of over-coding, under-coding, and flat-coding.
- Regular audits will help you make sure you have proper documentation and are receiving accurate reimbursements. Under- coding and flat-coding are generally more common than over-coding.