Q&A: Improving documentation of medical necessity

Q: How can we help our physicians improve their documentation of medical necessity?

A: Experts advise that the medical necessity documentation to justify acute care should demonstrate complex medical decision-making 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 or history of present illness if in emergency department 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.