Medical necessity in the outpatient arena

The use of clinical documentation integrity (CDI) in the inpatient realm is a well-known commodity for ensuring accurate coding and documentation to optimize revenue payment. However, an outpatient CDI process can also help accurately capture reimbursement and quality metrics for documenting medical necessity for outpatient care services rendered to patients in an office setting, outpatient hospital, ambulatory care center, and emergent/quick care, non-appointment-based services. Accurate clinical outpatient documentation with clear treatment and care plans is a key communication tool for healthcare providers.

As we look to improve medical necessity in the outpatient arena, there are essential items that should be included as a standard price for an outpatient visit, such as: 

• All diagnoses (new, chronic, acute, wellness, screening) clearly documented and connected to the patients’ chief complaint
• Avoidance of underdocumenting; sparse or unclear documentation
• Clear reason for the visit
• Clearly established medical necessity in the documentation
• Clinical assessment and plan of care clearly documented and related to the reason for the visit
• Clinical notes that contain all the elements required to support the level of service selected
• Documentation that supports the level of service billed
• Physician or provider notes reflecting all the elements of history, exam, and medical decision-making to support the level of service for the outpatient encounter 

In addition, to ensure that the medical necessity component is established, the clinical note should contain a clearly stated chief complaint. The chief complaint (sometimes noted within the documentation as the CC) is a concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other factor as the reason for the encounter and is usually stated in the patient’s own words. The chief complaint cannot be inferred. The physician or provider must clearly notate if the patient is there for follow-up visits/treatments, or the physician should document and provide a clear explanation identifying the problem and/or condition that is prompting the patient visit. If the reason for the visit is not provided within the record, a query should be made, and an addendum to the note needs to be added by the physician.  

Editor’s note: This article is an excerpt from “The Complete Guide to Medical Necessity: JustCoding’s Training and Education Toolkit” by Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC