In nursing home settings, ensuring medically necessary visits by physicians or Qualified Healthcare Professionals (QHPs) is critical for providing high-quality care and maintaining compliance with Medicare guidelines. This whitepaper outlines the definition of medical necessity, Medicare’s guidance on billing and documentation, and key considerations for determining the necessity of patient visits.
Definition of Medical Necessity
Medicare defines medical necessity as: “Services or items reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”
Medicare’s Guidance
Medicare emphasizes the importance of medical necessity in determining the appropriate level of E/M services. Specifically, Medicare states: “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of an E/M visit code. It would not be medically necessary or appropriate to bill a higher level of E/M service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported.”
Considerations for Patient Visits
To ensure that each visit is medically necessary and appropriate, healthcare providers could ask themselves the following questions before rounding on their patients:
- Why am I seeing this patient today?
- Has there been any report of a change in their condition?
- When was the last time I saw this patient?
- What did I see them for at the last visit?
- Could this have been addressed at the last visit?
Documentation Guidance
Accurate and detailed documentation is essential for supporting the medical necessity of patient visits. Healthcare providers should follow these guidelines:
- List the primary diagnosis, condition, problem, or other reason for the visit.
- Document and select ICD-10 codes to the highest level of specificity.
- Be precise and detailed in describing the condition, problem, illness, or disease.
- Make the distinction between acute and chronic conditions when appropriate.
- Make the distinction of the acuity of the patient’s current condition.
Frequency of Visits
Seeing every patient multiple times per week may not always be clinically indicated. However, there are cases where frequent visits may be necessary. It is essential to evaluate each patient’s condition and determine the need for a visit based on clinical indicators and changes in their health status.
Conclusion
By carefully assessing the necessity of each patient visit, healthcare providers can ensure that their care aligns with Medicare’s guidelines for medical necessity, leading to accurate billing, effective patient care, and compliance with regulatory standards. This approach not only supports the financial health of healthcare practices but also enhances the overall quality of care provided to nursing home residents.
LW Consulting, Inc. (LWCI) offers a comprehensive range of services that can assist your organization in maintaining compliance, identifying trends, providing education and training, or conducting documentation and coding audits. For more information, contact LWCI to connect with one of our experts!
