CDI and Medical Necessity: Closing the Gap Could Prevent Denials

Medical policies are based off of evidence-based medicine. Without proper documentation, however, most providers struggle to get services or procedures covered for patients.

Exactly what is medical necessity? To many, it is the belief that a service or procedure is warranted or justified for a patient. Others view it as a way for health plans to deny coverage for a service.

The American Medical Association (AMA) defines medical necessity as “healthcare services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing, or treating an illness, injury, disease or its symptoms in a manner that is (a) in accordance with generally accepted standards of medical practice; (b) clinically appropriate in terms of type, frequency, extent, site, and duration; and (c) not primarily for the economic benefit of the health plans and purchasers or for the convenience of the patient, treating physician, or other healthcare provider.” The “prudent physician” standard of medical necessity ensures that physicians are able to use their expertise and exercise discretion, consistent with good medical care, in determining the medical necessity of care to be provided each individual patient.

This is the standard many health plans adhere to and on which their typical payment policies are based. It’s also where we typically run into issues. Medical policies, at their cores, are based on evidence-based medicine. Without proper documentation, most providers struggle to get services or procedures covered for patients. This typically results in frustration and many phone calls to justify the services or procedures.

According to National Institutes of Health (NIH), evidence-based medicine (EBM) is the conscientious, explicit, judicious, and reasonable use of evidence in making decisions about the care of individual patients. EBM integrates clinical experience and patient values with the best available research information. It is a movement that aims to increase the use of high-quality clinical research in clinical decision-making.

EBM requires new skills of the clinician, including efficient literature-searching and the application of formal rules of evidence in evaluating clinical literature. The practice of evidence-based medicine is a process of lifelong, self-directed, problem-based learning, in which caring for one’s own patients creates the need for clinically important information about diagnoses, prognosis, therapy, and other clinical and healthcare issues.

When you pull these concepts together, this is how clinical indicators and polices are derived. Tailoring your clinical documentation to meet these criteria can help reduce administrative burdens and enhance the patient experience.

Most often, I see practices look at a policy and go straight to the covered diagnosis and procedural codes. This leads to a documentation fail.

Surgical practices are the most well-versed in clinical indicators, but they typically fail to tie them into the documentation. There are certain strategies you can employ to make this task more streamlined.

Let’s use cataracts as an example. Outside of your typical consent or treatment forms, you would want to make sure to use templates or documentation strategies that would capture the following for cataracts in the adult eye:

• The type of cataract
• Any ocular comorbidity, such as amblyopia, ARMD, diabetic retinopathy, glaucoma, strabismus, uveitis, etc.
• High-risk characteristics such as anterior megalopia, corneal opacification, high hyperopia, high myopia, miotic pupil, posterior polar cataract, prior keratoplasty, psuedoexfoliation, etc.
• Systemic comorbidities, hypertension, diabetes, heart disease, etc.
• Testing performed with interpretation and report
• Expected outcomes
• Management plan
• Counseling and referral

By building these into your standard documentation strategy, you will be able to support medical necessity, risk management, patient engagement, coding, and overall compliance. Utilizing the evidence-based nature of the guideline in your clinical documentation will enable you to improve and streamline your practice efficiencies.

For clinical documentation improvement (CDI) specialists, incorporating these into your teaching can help make it meaningful for a provider and help you gain buy-in and take any confusion out of the entire process.