Medical necessity is the concept that healthcare services and supplies must be necessary and appropriate for the evaluation and management of a given disease, condition, illness, or injury. The care must be considered reasonable when judged against current medical standards of care.

But clinicians know that guidelines are really not strictly black and white; they are guidance, but not necessarily a blueprint for mandatory action. There is an adage that “medicine is an art, not a science,” which in this case can be interpreted as reflecting that notion.

To protect against medical necessity denials, one must practice medicine that is reasonable, necessary, and appropriate, and the healthcare services provided must be in accordance with generally accepted standards. Patients can’t be admitted or treated at the convenience of the doctor, as in “I need to perform a cesarean section on you this Monday because I am going on vacation on Thursday.” Nor can a patient be admitted because it is easier to get the entire work-up done in the hospital as opposed to demanding multiple outpatient encounters. It is not reasonable to use a wildly more expensive or untested treatment on a patient when there is an efficacious and more cost-effective therapy available.

This all stems from the era of fee-for-service healthcare, wherein you get paid for what you do. If you perform more tests and require more patient visits, you stand to benefit financially. This is undesirable for the government, which happens to be the largest healthcare payer. Medical necessity is becoming more relevant to healthcare providers (HCPs) in this age of population health management, whereby the HCP accepts some financial risk. When there is capitation, HCPs tend to be more fiscally conservative in prescribing studies and work-up, because the cost directly impacts their bottom line.

In order to prevent medical necessity denials, the most important actions a provider can take are to be sure to put the patient in the correct status (i.e., admission versus observation) and in the right setting (i.e., general medical floor versus intensive care unit) – and to support medical necessity of testing in their documentation.

This article is going to home in on the documentation aspect of medical necessity. If medical necessity does not seem to be supported by the documentation, one of two things has occurred: the service was not medically necessary, or the HCP did not give enough clinical support for the reviewer to recognize the medical necessity. I am going to state now for the record that it is preferable to invest a few sentences up front to support a medically necessary admission or treatment rather than to expose oneself to the time drain that is denial appeals.

As an ex-emergency physician, it particularly irks me when I review a record from an emergency department encounter, or a history and physical, wherein the chief complaint is not addressed in the impression list. If a patient has a chief complaint of abdominal pain and your clinical evaluation leads you to admit the patient for a gangrenous right foot you discover on physical examination, somewhere on your list of diagnoses you should have a note that pertains to abdominal pain. It could be “irritable bowel syndrome” or it could be the sign/symptom of (please specify location of) abdominal pain.

A corollary to having a diagnosis for the chief complaint is having a diagnosis corresponding to any laboratory test, imaging or other study, or consult. The quintessential example from Emergency Medicine 101 is the syncopal fall from a cardiac dysrhythmia. You don’t X-ray an ankle for new-onset atrial fibrillation with a rapid ventricular response. It does not meet medical necessity. You may X-ray, however, for “right ankle pain, s/p fall,” or “right ankle swelling.”

Sometimes I get asked what to do if the complaint is not on the approved diagnosis list for the procedure. My response is, “first, reconsider whether the test is really indicated,” and, next, to “tell the truth.” It is better for the hospital to eat the cost of a head CT that “isn’t justified” because some bean counter forgot to put a rational diagnosis on the LCD/NCD than to have your family only get to visit you once a week at a federal penitentiary where you are incarcerated for fraud.

Your documentation must support the level of care. There are two main clinical criteria used as guidance for case managers, utilization reviewers, and auditors: McKesson’s InterQual Criteria and MCG (Milliman Care Guidelines). These are evidence-based clinical guidelines reviewers use to assess whether a patient’s level of care was appropriate or not. Although very useful, they are not incontrovertible clinical practice standards of care. Each HCP must use his or her clinical experience and expertise, and in doing so they may legitimately draw a different conclusion.

The problem arises when the HCP does not document the thought process adequately, and when the only reference the reviewer considers are those clinical criteria guidelines. Clinical judgment may supersede the guidelines, but the HCP must explain why this patient with these acute and chronic conditions, these specific vital signs, and these particular social, medical, and family history details justifies a different approach or status or setting than the published criteria would suggest. Why are you worried about this patient in this situation? Upon what alternate evidence-based clinical criteria or expert consensus guidelines are you relying? If the IQ or MCG say < 60 and your patient has a level of 62 but there are mitigating factors, spell that out.

Here’s a secret some HCPs don’t know. They don’t need to say the same thing every day, in every note. They need to document daily why each patient is still in the status he or she is in, and why they are getting the treatment they are getting today. Copying and pasting is an enemy to supporting medical necessity. You may perform an awesome medical decision-making assessment and plan on Day 1, but it is not as impressive when it is copied and pasted verbatim into Day 4’s daily progress note. Mindfully edit and justify your medical necessity today. Don’t let the only change from day to day be the day of the week.

Avoid inconsistencies or outright contradictions. If a patient is “stable,” he or she probably doesn’t warrant admission to the ICU. I used to see patients with florid pulmonary edema in acute hypoxic respiratory failure in the ED. If I stood by your bedside for five minutes with a 7.5 ET tube in my left hand waiting for the Lasix to kick in, you were going to a monitored setting, even if you turned around and looked like a rose. You are not “stable” until you remain improved for a significant period of time. You are in “guarded” condition in that circumstance.

I also recommend avoiding language such as “patient is without complaints” or “had an uneventful night.” Why is the patient still in the hospital then? “There is no significant improvement,” or “although improved, still with…” is preferable. Focus on what is still preventing transfer to a lower level of care or discharge home. What are you actively managing?

HCPs should document to get the most accurate ICD-10 codes that paint a picture of the patient’s conditions. I know it’s an “ASSLL,” but the HCP should record acuity, severity, specificity, laterality, and linkage. This gets the coder the most precise codes that risk-adjust for inpatient and outpatient methodologies (DRGs, HCCs). This makes the patient look as sick in the medical record as he or she is in real life.

I once reviewed a 20-day stay for cellulitis that was denied. There was an attempt made to convert it to an observation status after the fact. When I spoke with the infectious disease consultant, he said “it was the worst-looking cellulitis I had ever seen.” My response was, “why didn’t you document THAT?” An auditor might have given this one a pass had she read, “in my 27 years of practice, I have never seen a leg so horrible-looking. I am very concerned that this patient may have necrotizing fasciitis and is at high risk for losing her leg.”

Case management (CM) input is invaluable. When I was making disposition decisions, I relied heavily on CM to guide disposition status. But if on occasion they recommended a status or setting I felt was ill-advised, I would advocate for the patient and beef up my documentation to reflect my thought process. I trusted my clinical judgement over some cookie-cutter criteria whose authors were not sitting at my patient’s bedside.

Sorry if you are sick of reading the same old refrain from me. Take excellent medical care of your patients, and make them look as sick in the electronic medical record (EMR) as they look on the gurney. Tell the story and tell the truth. This is how medically necessary clinical care will meet medical necessity for a reviewer.

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