Coding for Medical Necessity

Coding for Medical Necessity

Introduction

For starters, medical records can ideally be defined as documents that delineate the medical history, medication history, clinical findings, diagnostic test outcomes, and pre and postoperative care of individuals. Good medical records- be it electronic or paper-based- are critical for the continuity of care for patients (Bali, 2019). For physicians, nurses, and other members of the allied healthcare profession, good medical records are essential in defending clinical negligence by virtue of the fact that they accord a window to the clinical judgment and decisions that were being exercised at that particular time.

Contents of Medical Records

For medical records to be deemed as being good or effective, they ought to contain certain crucial facets.  These contents include:

Identification Information (Demographics): Every well-drafted medical record must contain information that binds it to a given patient. Such information may be as simple as their patient’s name or initials, their social security ID, state alongside federal-issued identification number (American Retrieval, 2019).

Patient’s Medical History: According to the American Retrieval, every person has a medical history. Even individuals who have never seen a physician also have their medical history. As such, the common medical histories that are commonly captured in medical records include past and present diagnoses, medical and surgical care, treatments, and allergies. Bali (2019) affirms that even the absence of the need for medical care is usually captured in an individual’s medical history. The author attributes this to the fact that the information paints a picture of the patient through the identification of ailments or illnesses that are either acute, chronic, situational, or seasonal.

Medication History: The medication history of the patient is also another pertinent information that must be entailed within the medical record, as what an individual ingests has the potential to affect their health. For this reason, the medication history encompasses prescribed medications, over-the-counter medication, herbal remedies, and illegal substances that an individual has used at one point (American Retrieval, 2019).

Family Medical History:  A comprehensive medical record must also capture the family history of the patient. The vast proportion of medical conditions tend to be genetic, which makes them critical additions (American Retrieval, 2019).

Description of SOAP Notes

SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The SOAP approach is utilized by clinicians in the documentation of notes in an individual’s chart.

Subjective: The initial step in the SOAP approach for note-taking is the collection of all the information that the patient has to disseminate concerning their symptoms. It is expected that individuals will talk about their experience with the condition or symptoms and what they perceive to be their needs and treatment goals. Subsequently, best practices stipulate that clinicians should always record the patient’s own words instead of paraphrasing them to cultivate the most accurate insight regarding the condition. Some of the considerations that medical providers must take into consideration when retrieving the subjective data include:

Determination of when each symptom commenced manifesting.

Determination of the central location of the discomfort or pain.

Familiarization of how the patient has dealt with the clinical manifestation

Examination of the type of pain

Alleviation factors of the symptoms (Boyles, 2018).

Objective: Boyles (2018) affirms that the objective phase is primarily concerned with the raw information or data rather than the conclusion on the side of the healthcare provider. The documentation of the objective phase distinguishes the symptoms from the signs. Although used synonymously, symptoms are based on the individual’s own experience, while signs are based on the objective observations made by the clinicians.  For instance, if a patient reports having symptoms of hypertension, such as anxiety, fatigue, and angina, some of the vital signs that the clinician may measure to ascertain diagnosis include blood pressure rate, heart rate, respiration rate, and temperature (Krishna & Khosla, 2021).

Assessment: The subjective and objective data and information captured in the previous sections come into effect in the assessment phase. In this section, the clinician documents the impression that they have gathered and, as such, generates interpretations. Krishna and Khosla (2021) affirm that for an initial visit, the assessment section of a clinician note may or may not encompass a diagnosis based on the type as well as the severity of the symptoms that have been reported or signs that have been observed. Nonetheless, for follow-up visits, the assessment portion of SOAP ought to cover an appraisal of how the client is progressing towards the desired outcomes or rather the treatment goals (Boyles, 2018).

Plan: Ultimately, in the planning section, all three sections of the SOAP approach are integrated to aid the clinician in determining the best course of future treatment. As such, this section must contain the following information:

The intervention was administered in the current session alongside the rationale behind its administration.

The immediate response of the client to the intervention.

The scheduled date for the follow-up

Instructions provided to the client

Goals alongside outcome measures for new challenges or challenges that are being re-evaluated (Boyles, 2018).

The function of Operative Reports in Medical Necessity Coding

The operative report is a report documented in the medical record of a patient that documents the details of the surgery. This report is usually dictated immediately after a surgical procedure and later coded into the patient’s medical record. The information entailed in the report is integral for other clinicians attending to the postoperative recovery of the patients. Thomas (2019) affirms that operative reports are necessary as they provide evidence to show that everything that was performed on the patient during the surgical procedure was necessary for the patient’s condition. The author further suggests that operative reports come in handy during the submissions of claims for remuneration as the diagnosis codes reported by the service convey to payers why the particular service was undertaken.  To this end, it is worth mentioning that the diagnosis codes that are reported in the claim form should help support the medical necessity for the type of procedure that is performed on an individual.  For instance, if the diagnosis states that an appendectomy, the insurer is bound to only pay for the specific procedure.

National and Local Coverage Determinations

The National Coverage Determinations (NCDs) set forth the extent to which Medicare will offer coverage for specific procedures, services, and technologies deployed to patients on a federal basis. Subsequently, NCDs are binding to all health organizations, quality improvement organizations, competitive medical plans, and healthcare prepayment plans. The extent of the coverage of NCDs lies solely with the Secretary of the Department of Health and Human Services, who is tasked with the responsibility of determining whether a particular service or item is covered federally medically, which limits, excludes, or grants federal coverage to all beneficiaries of Medicare (American College of Radiology, 2016).

In contrast, Local Coverage Determinations are decisions formulated by a Medicare Administrative Contractor on whether to offer coverage to a specific item or service within a Medicare Administrative Contractor’s jurisdiction in alignment with section 1862(a) of the Social Security Act. The American College of Radiology (2016) suggests that LCDs are frequently published on matters that have proven to have a high error rate and require further clarification alongside guidance.  Due to variances in the jurisdiction of MAC, LCDs tend to differ from one region to another region, meaning that they are only applicable to the region served by the MAC that formulated the decisions. For this reason, LCDs must be in alignment with all laws, rulings, regulations, coding, and payment policies.

Conclusion

Conclusively, medical records encompass documents that delineate the medical history, medication history, clinical findings, diagnostic test outcomes, and pre and postoperative care of individuals. Good medical records- be it electronic or paper-based- are critical for the continuity of care for patients. For medical records to be deemed as good, one criterion that they must meet is the inclusion of the medication history of the patient. Notably, what an individual ingests has the potential to affect their health. For this reason, the medication history encompasses prescribed medications, over-the-counter medication, herbal remedies, and illegal substances that an individual has used at one point.

References

American College of Radiology. (2016). National and Local Coverage Determinations. Acr.org. https://www.acr.org/Advocacy-and-Economics/Radiology-Economics/Medicare-Medicaid/Coverage

American Retrieval. (2019). Electronic Medical Records: The Components of a Medical Record. American Retrieval Company. https://www.americanretrieval.com/medical-record-components

Bali, A. (2019). Management of Medical Records: Facts and Figures for Surgeons. Journal of Maxillofacial and Oral Surgery, 10(3), 199–202. https://doi.org/10.1007/s12663-011-0219-8

Boyles, O. (2018). Tips for Writing Better Mental Health SOAP Notes [Updated 2021]. notes. https://www.icanotes.com/2018/04/25/tips-for-writing-better-mental-health-soap-notes/

Krishna, K., & Khosla, S. (2021). Generating SOAP Notes from Doctor-Patient Conversations Using Modular Summarization Techniques. ArXiv:2005.01795 [Cs, Stat], 11(22). https://arxiv.org/abs/2005.01795

Thomas, J. (2019). Medical records and issues in negligence. Indian Journal of Urology, 25(3), 384. https://doi.org/10.4103/0970-1591.56208

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Understanding the electronic medical record is important for properly coding a bill for medical necessity. This record contains information about the patient’s health both before and after treatment and has the data needed to assure a payer that the treatment was necessary.

Tasks:
Explain the contents of the medical record.
Describe SOAP notes—subjective, objective, assessment, and plan.
Explain how operative reports function in medical necessity coding.
Explain National and Local coverage determinations.
Submission Details:
Submit the report as a 5—to 10-page Microsoft Word document. Citations and references should follow APA standards.
Cite a minimum of three outside peer-reviewed sources to support your assertions.