As is the case with patient’s history, payers and auditors use a similar logic for establishing medical necessity when scanning the PE records for over-documentation. Reviewers may identify elements of the PE that are not consistent with the CC and may determine that services were not medically necessary, thereby decreasing the overall level of the PE. Providers should double check documentation of the CC against the PE to ensure that medical necessity has been established.
Medical Decision-Making Documentation Pointers
Medical Decision Making (MDM) is an assessment plan, the provider’s thought process in devising a treatment plan based on the patient information available to him. MDM documentation has benefitted greatly from the advent of EMRs, as providers need to clearly detail their plans and the problem list.
Expert tips to remember:
Divvy Up the MDM with the Decision-Making Matrix
CPT® has a decision-making matrix that physicians typically don’t utilize as much as they should.
|# DXs Manage
|Type of Medical
Rule: A provider must attain two out of three components for eligibility to report the desired level.
In theory, physicians would use this matrix and ask themselves when they’re documenting and subsequently coding, “How do I fit into this matrix?” The answer is not straightforward.
Bird’s Eye View: The words’ minimal,’ ‘limited,’ and ‘multiple’ are subjective. ‘Minimal’ could mean almost zero, or perhaps one. ‘Limited’ could mean two or multiple.
Red flag: Physicians must indicate which documentation they have reviewed. While they may not make that documentation a part of the record of this encounter, they can indicate that they reviewed the old X-ray charts, EKG scans, and similar. That review will lend support to the level of decision making.
Plus: The provider should factor in the risk of complications. A patient with a cardiac problem would run a higher risk of complications than a patient with a painful knee.
Lesson: Considering that risk of complications drives up the level of decision making, documenting to that fact substantiates that the level of MDM was significant. MDM drives medical necessity.
Master accurate and timely documentation that reflects the scope of services provided with TCI’s Clinical Documentation Sourcebook 2018.