Medical Necessity and Nature of Presenting Problem
Documentation Tips: Medical Necessity and Nature of Presenting Problem
Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation is not the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported.
The extent of the H&P required is usually determined by the severity of the presenting problem. CPT describes the varying degrees of nature of presenting problem (NOPP) and associated ED EM levels as follows:
Self-limited or minor (99281): A problem that runs a definite and prescribed course, is transient in nature, and is not likely to permanently alter health status OR has a good prognosis with management/compliance.
Low severity (99282): A problem where the risk of morbidity without treatment is low; there is little to no risk of mortality without treatment; full recovery without functional impairment is expected.
Moderate severity (99283): A problem where the risk of morbidity without treatment is moderate; there is moderate risk of mortality without treatment; uncertain prognosis OR increased probability of prolonged functional impairment.
High severity (99284 & 99285): A problem where the risk of morbidity without treatment is high to extreme; there is a moderate to high risk of mortality without treatment OR probability of severe, prolonged functional impairment.
The following are critical ways to support medical necessity in chart documentation:
- Be as descriptive as possible in your documentation of the History of Present Illness to paint a picture of why the patient needed to be seen in the ED including relevant conspiring medical history, severity descriptors, complicating factors, pre-arrival treatment, etc.
- Document your Medical Decision Making or clinical thought process. Recording only a diagnosis in this portion of the chart will not singularly support a level of service. The following are indicators that will either support the emergency provider’s Medical Decision Making or attest to the patient’s nature of the presenting problem.
- Record worded interpretations of those studies on which you based the patient’s management in the ED or your clinical conclusions. Don’t let important findings be missed by a casual reader. Most reviewers are not motivated to dig through your work.
- List the treatment interventions performed, the patient’s responses and, most importantly your serial assessments and bedside evaluations. Did the patient’s condition deteriorate, stabilize or improve? Was a change in modalities required? If so, it should be documented.
- Record consultations, arrangements for transfer, conversations with other practitioners or family members, the implication of surgery, stress testing, angiography, etc.
- Document differential diagnoses that were considered based on the patient’s presentation, history, exam, and risk factors.