Query for Medical Necessity

jprice

I would like to ask the group about queries for Medical Necessity.

Is anyone doing them?

Do they have the same Compliance implications?

Are they up for the same issues of "leading" as those for CC's and
MCC's?

Our situation is related to DRG 470. CMS is doing an audit on this DRG
for Medical Necessity. One of the elements is that prior treatment is
not indicated in the record (conservative treatment failure,
radiological reports to support necessity, affect of pain on ADL's
etc).

This documentation is sometimes included in the OP Report, or the H&P.

We are tempted to query the physician if the info is missing, based on
our timing and interaction with the chart before discharge.

Your input is greatly appreciated! Thank you in advance!

JoAnne Price MSN, CDIS
Kingman Regional Medical Center

Unknown

I am not yet querying for medical necessity
A query is a query, should never be leading
DRG 470 is and excellent query opportunity for the elements CMS requires to support the procedure
I would be all for querying if the indicators are missing

Charlene Thiry RN, BSN, CPC, CCDS
Clinical Documentation Specialist
Quality Resources
Menorah Medical Center

Unknown

Querying for additional information that supports the physician's clinical judgment and medical decision-making is not in any form or fashion "leading." As opposed to "querying" the physician for the specific clinical elements that led him/her to recommend and perform surgery, the preferred method of physician education is to engage the physician in a candid conversation of what is the physician responsibility in determining medical necessity. The ultimate responsibility of determining medical necessity for surgical services or any other healthcare related service for that matter is with the physician. I refer you to the American Board of Healthcare Quality and their position on medical necessity, that is it is the physician's responsibility in demonstrating through effective clinical documentation the medical necessity for a service as opposed to the insurance company or Medicare. The physician unfortunately handicaps his/her practice of medicine by taking short cuts and generally practicing poor documentation patterns.



I also refer you to the ACS Statement of Principles regarding physician responsibility in demonstrating medical necessity and adhering to government and other third party payer mandated requirements for documentation. Check it out

http://www.facs.org/fellows_info/statements/stonprin.html