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The Value of the ‘Why’ Explanation in Clinical Documentation
By Greer Contreras, CPC

The complexity of our industry’s reimbursement systems combined with the current regulatory scrutiny of billing and coding for evaluation and management (E/M) services further underscores the importance of relevant documentation. Clinicians need to clearly express the “why” behind the work they are performing when entering their documentation.

Understanding and then determining the medical necessity of a patient’s medical treatment is a frequently misunderstood concept. Providers often have an entirely different interpretation of what constitutes appropriate documentation of medical necessity than payers, auditors, and coders.

The Centers for Medicare and Medicaid Services states that “no Medicare payment shall be made for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.” To apply the essence of this statement to the entire E/M service, the clinician must clearly demonstrate not only the need for the treatment(s) rendered and the diagnostic workup required but also the extent of the history taken and examination performed.

So how do physicians paint the picture of a patient visit? They should start at the beginning with the clinical assessment, where the patient presents at least one complaint, if not multiple. Then they should document not only the complaint(s) but also the patient’s answers to clinically relevant questions. For example, they should document the severity of a patient’s signs and symptoms, fully describing the context surrounding them, as well as the time period during which the symptoms have been experienced and whether any action has been taken that improved or worsened the symptoms. In other words, they should use vivid descriptions of the patient’s reasons for the visit because doing so establishes a clinically robust documentation foundation to build on.

This thorough knowledge capture leads to the performance and documentation of the physical examination, the extent of which should be based on clinical relevance of the presented problem(s) and any risk factors identified in the patient’s encounter history. Tying these related details together helps define the medical necessity of both the historical and the physical examination portions of the visit.

Physicians also must be aware when documenting the difference between medical decision making and medical necessity. Medical decision making is the “work” portion of the visit, both cognitive and physical. Medical necessity is the “why” behind the work being performed. Physicians should thoroughly describe their thought process, including discussions regarding the working differential diagnoses and the probability of potential outcomes—both adverse and positive. They should document coexisting conditions that affect a patient’s treatment plan along with the risk associated with these conditions, which again help to establish a clear picture of what is being evaluated and what is necessary to accomplish the evaluation. When ordering diagnostic tests and ancillary services, physicians should state the rationale behind the workup and be sure to document pertinent results and the treatment path necessary to manage the patient’s condition(s).

By completing all the documentation steps necessary to clearly demonstrate the visit, physicians will be prepared to help defend services to private payers or Medicare. The goal is limiting the need for inference within the patient’s record. High-quality clinical documentation makes this possible in revealing a full account of the clinical assessment, professional judgment, and critical thinking supporting the why behind the diagnosis and its necessity.

— Greer Contreras, CPC, is vice president of revenue cycle management compliance for T-System, Inc.