Question

List the providers requirements of documenting medical necessity for services or supplies

Answer 1

Answer:

Requirements of effective document of medical necessity:

1. Assessment
2. Planning care
3. Progress
4. Treatment plan reviews and assessment update

Explanation:

1. Assessment: examine the health status of the individual, predict their outcome and identify the critical clinical needs of them.

• Severity of the “signs and symptoms” or direct diagnosis exhibited by the patient. This is our diagnosis driver, and multiple diagnoses may be involved.
• Risk of an adverse or a positive outcome for the patient, and how that risk equates to the diagnosis currently being evaluated.
• Need and/or availability of diagnostic studies and/or therapeutic intervention(s) to evaluate and investigate the patient’s presenting problem or current acute or chronic medical condition. In other words, does the facility, office, or hospital have what the provider or clinician needs to render care?

2.  Planning care: identify goals, barriers and objectives that address the concerns of the individual.

3. Progress toward the identified goals and objectives

4. Treatment plan reviews and assessment update:

The service or treatment plan:

• Helps to integrate information about the person, the family, and members of the individual’s support system(s) as related to clinical needs.

• Facilitates prioritization of needs, interests, and recovery/rehabilitation goals.

• Provides a strategy for managing the complex needs of the individual and describes interventions which are defined by measurable outcomes.

• Is an ongoing process connecting clinical assessments with targeted service delivery?

Service plans should clearly demonstrate a legitimate clinical need, justification for the services provided, and appropriate response to clinical need. They should be based on an early, comprehensive evaluation of the client’s symptoms, needs, and prospects for improvement. A provider should meet with the client in person and then make specific written recommendations about what services are necessary, including: the type of services, how often, for how long, and provided by whom.

To sum up, each piece of documentation must flow logically from one to another such that someone reviewing the record can see the logic and understand the story you are telling about the individual’s treatment and progress.

Reference:

https://www.hca.wa.gov/assets/billers-and-providers/medical-necessity-documentation-guide.pdf