Q&A: Guidelines for documenting medical necessity

October 7, 2019
Medicare Web

Q: How can we encourage our physicians and nonphysician practitioners to better define medical necessity in their documentation?

A: Physicians should be encouraged to “think in ink.” Remember, CMS has stated that the physician’s “order and certification regarding medical necessity” are NOT entitled to any “presumptive weight” and are “evaluated in the context of the evidence in the medical record” (42 CFR §412.46[b]).

Experts advise that the medical necessity documentation to justify acute care should demonstrate complex MDM and should begin with the patient’s chief complaint, acuity of the patient’s condition, any comorbidities, why the nature of the patient’s condition warrants a hospital level of care, and the potential risks if the patient is not admitted. These four points—and their mnemonic, HOPE—may be helpful to the physician-coaching process.

  1. History & physical (H&P) or HPI if in emergency department (ED) and patient throughput is a priority
  2. Orders for a treatment plan with services and procedures that can only be safely provided at a hospital level of care
  3. Potential risk if patient is not treated in the hospital
  4. Expectation of 2-midnight stay in the hospital via a “because clause”

For more information, see the Hospital Guide to Contemporary Utilization Review, Second Edition.