Coding for Medical Necessity
Contents of a Medical Record
Medical records are documents containing a patient’s history and medical care. Medical records contain patients’ health information, including health history, diagnostic results, identification information and billing information. Accordingly, medical records were initially in paper form, but digital forms are now known as electronic health records (EHRs) due to technological advancements. EHRs contain vital signs, patient diagnoses, family history, medical history, immunization records, laboratory results, allergies, imaging studies, patient demographics, insurance information and progress notes (Liu S & Zeng R. (2020).
Medical records are documentation of episodic care. Medical records help healthcare professionals collect patient data, which facilitates the coordination of care among different healthcare professionals (Liu S & Zeng R. (2020). In addition, they allow healthcare professionals to track care which improves patient outcomes. Medical records are also used for administrative and reimbursement purposes (Liu S & Zeng R. (2020). These records have several benefits to healthcare providers and healthcare organizations. For instance, they reduce malpractice risks, improve healthcare information exchange and communication, ensure hospitals get reimbursed, and record hospital quality measures for public reporting (Liu S & Zeng R. (2020). Medical records include identification information such as date of birth, social security number, name and marital status (Liu S & Zeng R. (2020). Records also comprise medical history (allergies, treatment, diagnosis), medication information, family history, treatment history (chief complaints, vital signs, immunization history, developmental history, medical history and surgery history), medical directives, consent forms, progress notes and financial information (Liu S & Zeng R. (2020).
SOAP Notes: Subjective, Objective, Assessment, and Plan.
The SOAP note is a commonly utilized documentation method by caregivers. It allows caregivers to document care in a structured and organized way (Podder et al., 2020). It offers a framework for patient evaluation and clinical decision-making. It also guides caregivers in utilizing their clinical knowledge to evaluate, diagnose and treat patients depending on the information gained (Podder et al., 2020). They provide helpful information about the patient’s health status and serve as a communication document between healthcare professionals.
The subjective portion of the SOAP represents the patient’s experiences, feelings or personal views. This section includes the “chief complaint, history of presenting illness, medical history, surgical history, family history, review of systems, allergies and current medications.” (Podder et al., 2020). The objective portion documents objective findings from a physical examination. This section includes “vital signs, physical examination findings, imaging results, and other diagnostic data.” (Podder et al., 2020). Subsequently, the assessment portion documents the synthesis of evidence from the subjective and objective parts. Elements of the assessment portion include diagnosis and a list of differential diagnoses (Podder et al., 2020). The final part of the SOAP note is the plan. This portion documents further testing and consultation with other healthcare professionals. It includes additional diagnostic tests to rule out differentials, required therapy, consultations and patient education (Podder et al., 2020).
Operative Reports Function in Medical Necessity Coding
Operative reports are developed after every surgical operation for documentation and billing purposes. Even though some surgeons create operative notes utilizing structured tools, most operative reports are self-transcribed and reflect the surgeon’s recollections of the procedure performed (Eryigit et al., 2019). The operative report has a “procedure description” section that describes the actions performed and events observed during the surgical procedure (Eryigit et al., 2019). Operative notes are organized into several sections. The sections include pre-procedure diagnoses, the name of the procedure, post-procedure diagnosis, anesthesia used, complications, blood loss and a detailed procedure description (Eryigit et al., 2019). A narrative description of the procedure is the core element of the operative report. It is the most entitled “procedure narrative.” In addition to offering a specific description of what happened during surgery, the description contains detailed information concerning the materials, instruments, surgical maneuvers, patient-specific anatomy and equipment used during surgery (Eryigit et al., 2019).
National and Local Coverage Determinations
Healthcare services offered to Medicare beneficiaries must be necessary and reasonable for healthcare providers to be reimbursed. Even though Medicare determines if a service provided is reasonable and necessary, it also offers coverage determinations to guide what providers should be reimbursed for (American College of Radiology (ACR), n.d.). The two coverage determinations are the National Coverage Determination (NCD) and local coverage Determination. NCDs overrules LCDs, but LCDs expand coverage regulations for each jurisdiction. The information in the coverage policies includes diagnostic testing, coding, credentialing and treatment (ACR, n.d.). The general coverage information is found in LCDs, and healthcare providers must adhere to LCDs in their particular jurisdiction.
On the other hand, NCDs are mandated at the national level. All Medicare Administrative Contractors (MACs), fiscal intermediaries and carriers must adhere to these policies (ACR, n.d.). LCDs are mandated at the MAC levels, and these policies are only applied to the MAC’s jurisdiction. MACs develop LCDs if there are no NCDs or when a need arises for further definition of an NCD (ACR, n.d.). LCDs and NCS are decisions made by MACs to specify the services to be covered and not covered (ACR, n.d.). The difference between NCDs and LCDs is that NCDs are made at the national level, while LCDs are developed by MACs if there is no NCD.
References
American College of Radiology (ACR). (n.d.). National and local coverage determinations. Home | American College of Radiology. https://www.acr.org/Advocacy-and-Economics/Radiology-Economics/Medicare-Medicaid/Coverage
Eryigit, Ö., Van de Graaf, F. W., & Lange, J. F. (2019). A systematic review of the synoptic operative report versus the narrative operative report in surgery. World Journal of Surgery, 43(9), 2175-2185. https://doi.org/10.1007/s00268-019-05017-8
Liu S & Zeng R. (2020) Denomination, Format, and Content of Medical Record. In: Wan XH., Zeng R. (eds). Handbook of Clinical Diagnostics. Springer, Singapore. https://doi.org/10.1007/978-981-13-7677-1_67
Podder, V., Lew, V., & Ghassemzadeh, S. (2020). SOAP notes – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK482263/
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Question 
Review the following lecture:
Coding for Medical Necessity
Introduction:
In order to properly code a bill for medical necessity, it is important to understand the electronic medical record. This record contains information about the patient’s health both before and after the treatment and has the data needed to assure a payer that the treatment was necessary.
Coding for Medical Necessity
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. Use APA standards for citations and references.