Guest Post: Examine guidelines for medical necessity documentation needs

by Glenn Krauss, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS

Because most CMS local and national coverage determinations governing medical necessity and limitations of coverage center around outpatient procedures (e.g., lesion removals, cataract surgeries, and blepharoplasty repairs), typically physicians’ clinical judgment and medical decision-making alone have qualified as sufficient support for the need for inpatient procedures.

To meet medical necessity for commonly performed inpatient procedures (e.g., hip and knee replacements and spinal fusions), medical necessity for performing the procedure in and of itself is predicated upon supporting documentation in the physician’s office notes. Unfortunately, oftentimes this documentation is sparse, clinically nonspecific, and without sufficient detail to meet the stringent medical necessity requirements by Medicare and other third-party payers. The end result is medical necessity denials for these inpatient procedures for both the hospital and the surgeon. This makes for a tangled web from all aspects of the collection of health information.

Examine guidelines for reporting diagnoses and procedures

The Medicare Program Integrity Manual, chapter six, section 6.5.2, “Medical Review of Acute Inpatient Prospective Payment System (IPPS) Hospital,” and section 6.5.4, “Review of Procedures Affecting the DRG,” contains language on diagnosis and procedure code assignment:

“The contractor shall determine whether the performance of any procedure that affects, or has the potential to affect, the DRG was reasonable and medically necessary. If the admission and the procedure were medically necessary, but the procedure could have been performed on an outpatient basis if the beneficiary had not already been in the hospital, do not deny the procedure or the admission. “

Section 6.5.4 offers guidelines for the MAC when a procedure wasn’t medically necessary:

• “If the admission was for the sole purpose of the performance of the non-covered procedure, and the beneficiary never developed the need for a covered level of service, deny the admission;
• If the admission was appropriate, and not for the sole purpose of performing the procedure, deny the procedure (i.e., remove from the DRG calculation), but approve the admission.

In other words, if the clinical documentation does not clearly and unequivocally support the medical necessity for a procedure, the Medicare contractor will deny the entire stay for both the hospital and the physician. This congruent Part A and Part B denial for medical necessity is becoming more common from a MAC standpoint, as the following information published by MAC Trailblazer Health illustrates:

“Prepay service-specific edits are in place to review services billed with the following DRGs:

• 243, Permanent cardiac pacemaker implant with complications
• 246, Percutaneous cardiovascular procedure with drug-eluting stent with major complications or 4+ vessels/stents
• 247, Percutaneous cardiovascular procedure with drug-eluting stent without major complications
• 460, Spinal fusion except cervical without major complications
• 470, Major joint replacement or reattachment of lower extremity without major complication”

“To increase consistency in Medicare reimbursement, effective November 1, 2011, TrailBlazer began cross-claim review of these services. The related Part B services (i.e., procedure and evaluation and management services) reported to Medicare will be evaluated for reimbursement on a postpayment basis. Overpayments will be requested for services related to the inpatient stay that are found to be paid in error.”

Trailblazer outlines documentation requirements for DRG 470

Trailblazer Health has outlined and defined specific joint replacement (DRG 470) documentation for both hospitals and physicians to follow in support of medical necessity.

Clinical documentation from both the physician’s office as well as the hospital must support medical necessity for joint replacement procedures. Coders cannot directly control the quality and completeness of documentation in the record, but they can certainly familiarize themselves with the guidelines of clinical documentation necessary for joint replacements and apply this knowledge when reviewing these records.

Coders can collaborate with case managers and utilization review staff to identify documentation deficiencies, which place both the hospital and the physician at financial risk for recoupment due to a lack of medical necessity. To this end, consider developing a training program for physicians and other clinical staff that covers principles of documentation to establish medical necessity.

For example, physicians need to be aware that for a knee replacement, they need to document:

• Pain in the knee (e.g., level of pain and whether it has worsened)
• Pain increasing with activity (e.g., whether the pain increases with weight-bearing and daily activities)
• Passive or limited range of motion or swelling of the joints
• X-rays that support any of these findings:
  
  • Subchondral cysts
  • Subchondral sclerosis
  • Periarticular osteophytes
  • Joint subluxation
  • Joint space narrowing
• The use of medication that was unsuccessful in providing pain relief

This is quite a bit of information that the physician needs to document to support medical necessity, but without the proper diligence of various parties (e.g., utilization review, physicians, and coders), and without this supporting detail, it could lead to costly denials.

Editor’s Note: This article was originally published on JustCoding.com. At the time of this article's original release, Krauss was Executive Director of the Foundation for Physician Documentation Integrity.