The medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT (Current Procedural Terminology) code. Documentation of medical necessity should do the following:
- Identify a specific medical reason or focus for the visit (e.g., worsening or new symptoms)
- Document the rationale for ordering tests or referrals
- Describe how the patient/caregiver has managed chronic conditions from the previous visit to present or explain acute symptoms; status of three chronic conditions may be used for History of Present Illness (HPI) credit
- Include within the assessment and plan the provider’s clinical impression, condition status, and treatment plan for each diagnosis assessed that day
- Summarize the patient’s health (e.g., improved, worsening, not responding as expected) and document services performed, treatments recommended, medication management, education/counseling, and goals of care conversations
- Represent the patient complexity, overall patient risk level, and any aggregating factors or psychosocial challenges
- Document initiation of, or changes in, treatment
- Include patient and nursing instructions, therapies, and medications
Evaluation and Management (E/M) Documentation Requirements
- Chief Complaint (CC) and HPI
- Past, Family, and/or Social History (PFSH)
- Review of Systems (ROS)
- Exam
- Medical Decision-Making and Complexity
- Detailed Assessment and Plan describing the work and treatment decisions
Check out HCCI’s other education related to coding, billing and documentation here.