Medical documentation

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.