PHOENIX MEDICAL MANAGEMENT, INC.

No Payment may be made under Part A or Part B for any expenses incurred 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.

Most healthcare professionals consider a service medically necessary if it:

• Meets the provisions of a Local Coverage Determination (LCD) or National Coverage Determination (NCD)
• Is provided at the proper level of care (i.e., inpatient or outpatient)

However, medical necessity acquires new meaning in the context of recent Medicare Administrative Contractor (MAC), Recovery Audit Contractor (RAC) and CERT denials of clinical scenarios that at face value appear reasonable and necessary. Contractors are denying services because physician documentation did not meet reasonable standards to perform the procedures.

Transforaminal epidural injection denials

Special Edition MLN Matters article SE1102 cites “Inappropriate Medicare Payments for Transforaminal Epidural Injection Services,” an August 2010 OIG report. The OIG analyzed a random sample of 433 records involving transforaminal epidural injection services provided in 2007 and found that 34% of transforaminal epidural injection allowed by Medicare didn’t meet Medicare documentation requirements.

Local Coverage Determination L30481, which governs transforaminal injections, states that documentation must meet the following requirements:

• Documentation in the medical record must contain the initial evaluation including history and physical examination, diagnosis, pain and disability of moderate to severe degree, site of injection with name and dosage of drug instilled, and the patient’s response to the prior injections.
• Documentation of conservative therapies that were tried and failed except in acute situations such as acute disc herniation with disabling and debilitating pain, herpes zoster and post herpetic neuralgia, reflex sympathetic dystrophy, post operative and obstetric pain and intractable pain secondary to carcinoma.
• Pre and post procedure evaluation documenting patient’s response to the injection, including pain level and ability to perform previously painful maneuvers must be included in the medical record

Other documentation errors highlighted in the OIG report include the following:

• 19% of transforaminal epidural injection services had a documentation error
  • 10% were undocumented
  • 9% were insufficiently documented
• 13% of injection services had a medical necessity error and 8% had a coding error resulting in overpayments.
• Documentation errors occurred more often in office settings
  • 41% of all errors occurred in physician’s offices
  • 28% of all errors occurred from care provided in facilities

Other notable denials

Highmark Medicare Services, the region 12 Medicare Administrative Contractor (MAC), issued a notice summarizing denials for certain Medicare services from October to December 2010.  Access this notice at https://www.highmarkmedicareservices.com/cert/errors/pdf/a-cert-oct-dec-10.pdf ^[1].

The following denials and rationales are noteworthy from a case management perspective:

• Per CERT Medical Director: The procedure, 00.51, Implant CRT Defibrillator System was not reasonable and necessary. The Beneficiary is stated to have class III heart failure. NCD (National Coverage Determination 20.4 Publication 100-3, Version #3) requires class IV for CRT device. The documentation does not include additional MD discussion of other reasons for this device. Inpatient admission not medically necessary as this was an elective admission for a non-covered procedure.
• Per CERT Medical Director, ’there is no documentation to support the medical necessity of the total hip replacement. Therefore both the procedure and the inpatient admission are denied.’
• There are no National Coverage Determination (NCD) covered indications for the dual chamber pacemaker, There is no documentation of MD discussion of the reason for the dual chamber device. The inpatient admission was reasonable and medically necessary

Due to continued RAC, CERT, and MAC related medical necessity denials associated with pacemaker insertions, CMS developed a CERT Fact Sheet reiterating documentation requirements associated with pacemaker insertion. I encourage you to read it to help reduce medical necessity denials for pacemaker insertions, which are costly.

Read the fact sheet at http://www.cms.gov/MLNProducts/downloads/CERT_Pmaker_FactSheet_ICN905144.pdf ^[2].

I also call your attention to the recent article released by Noridian Administrative Services, LLC,  “Submitting Documentation to Support Procedures Billed.” Access this article at https://www.noridianmedicare.com/cgi-bin/coranto/viewnews.cgi%3fid=EkAAZAFZpyiTClLXNh&tmpl=part_a_viewnews&style=part_ab_viewnews ^[3].

Putting medical necessity in proper perspective

Medicare provides a general definition of medical necessity that embraces the concept of reasonable and necessary, it issues LCDs and NCDs that establish covered diagnoses and it instructs Medicare contractors to apply screening criteria when reviewing claims. The onus is on providers to ensure complete and accurate clinical documentation that supports medical necessity.

Providers must do more than ensure that diagnosis supports medical necessity and document whether an inpatient or outpatient setting is appropriate. Clinical documentation must reflect a physician’s clinical judgment, rationale, and medical decision-making for recommending a procedure for a patient. Documentation also must include the following:

• Any conservative  therapy attempted before deciding to perform surgery
• Clinical confirmation of the provided diagnosis rather than a mere conclusory statement
• A well crafted and concise “indication for procedure” within the body of the  required history and physical (H&P) before performing the procedure

The H&P often is nothing more than a completed from supplied by the primary care physician or consulting medicine physician who cleared the patient for surgery. This does not establish medical necessity for the performance of the procedure, regardless of patient status designation.

Case management professionals can and should work with clinical documentation improvement specialists to affect positive change in physician patterns of clinical documentation.