Is that necessary?

Published: 2010-11-20 20:14:11
Author: Marc Sencer | ChiroEco | October 2010

In clinical practice, you are often asked to justify your actions in terms of medical necessity. An intervention is medically necessary if it is reasonable and necessary for diagnosis or treatment, and can potentially improve the condition being treated such that the patient can experience increased function or quality of life.

In order to have medical necessity, it is not necessary that the intervention be the only one that will help, but it should be the one that poses the least risk to the patient.

For example: Spine surgery would not be medically necessary for a tension headache when an adjustment or Ibuprofen may very well be curative.

On the other hand, in a patient with severe worsening acute disc syndrome with foot drop, surgical decompression may be medically necessary — where less risky procedures would not be helpful and would lead to irreversible loss of function.

Medical necessity will vary over the course of treatment. Typically, the more conservative therapies will be medically necessary during the initial phases, and more invasive treatment will be necessary only if initial treatment fails.

Documenting necessity

Documentation of medical necessity is important in the defense of malpractice lawsuits and professional board disciplinary actions, but the most common scenario where it comes into play is in disputes with insurance companies over reimbursement.

There are two important types of documentation of medical necessity. The first is your written treatment notes. It goes without saying you must document everything you do. If it is not in the chart, it doesn’t exist.

In addition, you should try to give a rationale for what you are doing. A problem/ plan list in the treatment plan is helpful. For example: L5/S1 Paresthesias / MRI L Spine; R/O Nerve Root Compression.

Insurance companies like to see you start with conservative treatment and progress to more invasive interventions. Make sure the treatment notes reflect your conservative approach. “Shotgunning” the patient with multiple expensive tests on the first treatment day will be hard to justify as medically necessary.

The second type of documentation of medical necessity you may be required to produce is a letter of medical necessity. Look at this as an opportunity to make your case to the insurance company, plaintiff attorney, or professional board that may have requested it.

The medical necessity letter provides you an opportunity to amplify the information in the chart. Unfortunately, it is not a free pass to add or amend what is missing from your treatment notes.

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