In Part One of this article, we looked at medical necessity “traps.”  In other words, things NOT to do when attempting to document or meet criteria for medically necessary care.

We also discussed that one of the challenges with mastering the maze of medical necessity is that the definitions may vary from payer to payer.  However, don’t lose hope.  There are a few common elements that contribute to most payer requirement.

Here are ones that are often missed, but frequently needed in establishing your care as medically necessary:

B-C-D Matchup. Perhaps one of the most overlooked, yet simple tests for medical necessity is the Billing-Coding-Documentation Matchup.  Essentially, all this means is that you have billed a 98941 then your diagnosis coding must communicate that you have a three to four region adjustment and your documentation must correlate as well.  An auditor who reviews a 98941 claim and detects that only two spinal areas have been diagnosed need go no further: the claim does not meet medical necessity. Similarly, if the billing and the coding match, but the documentation only supports a two level adjustment, medical necessity is also not met.  To prevent this from happening, use claim “scrubbing” software or have your billing personally manually check that these errors do not leave your office.

Response to Care.  Here is another area easily overlooked that can be fatal towards your attempts at proving medical necessity.  Basically, you need to indicate the patient’s response to your care in your documentation.  In doing so, the essential point you want to communicate is this: can an outsider view your treatment notes and get the impression that the patient is progressing, staying the same or getting worse with care.  While it may sound horrifying to report that a patient is worse, reviewers understand that you are not obligated to be a miracle worker. However, a consistent downward spiral would probably indicate your care is not needed, because it is not working.  On the other hand, an auditor does not always assume your care is getting the patient better because they do not have the benefit of being a first hand observer to the patient’s progress, as you are.  Therefore, the best remedy is to always indicate a response to care so that you can clearly depict the results your treatment is getting.

Be Fixable.  A final stumbling block I have observed in medical necessity documentation is the concept of treating a “fixable” condition.  The buzz word “functional improvement” goes a long way in describing how we should approach our treatment and its medical necessity.  Sometimes, this is quite simple.  A patient with mid back pain has restricted motion of the thoracic spine.  The chiropractor’s adjustment restores motion and alleviates the back pain. Certainly this would meet medical necessity in the basic sense.  Now, complicate that scenario by stating that the patient also had severe, longstanding degeneration in the mid back.  Here, the chiropractor may not actually be able to reverse the degenerative process with the adjustment, but the end result is the same: the adjustment improves motion and pain is relieved.  If the chiropractor is able to document the functional losses from the condition at hand and the resulting functional improvements due to chiropractic care, most would agree this meets medical necessity.  While the condition may not be “curable” via the chiropractic adjustment due to the degenerative process, the painful situation the patient is experiencing is
“fixable” and can meet medical necessity if documented accurately.

For many there is a great mystery surrounding the idea of medical necessity.  I hope this article sheds some light on this topic and illustrates how you can properly bill, code and document your care to meet medical necessity.

Tom Necela, DC, CPC, CPMA