BC Advantage - 2018 Issue 8
When Medical Necessity and Medical Decision Making Don't Match
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Article Overview
This article explains the relationship between medical necessity and medical decision making in evaluation and management documentation. It is written for coders, auditors, and compliance professionals who review E/M records and need to understand broad concepts used to assess the level of service, including how history, exam, and provider thought process contribute to the overall picture. The article also references a third-party tool used to help gauge medical necessity across several service settings.
Why This Topic Matters
Accurate E/M review depends on recognizing when the documented medical necessity is stronger than the apparent medical decision making. Understanding that distinction helps auditors and coders evaluate records consistently and identify documentation gaps without relying only on checkbox-based review.
What You Will Learn
- How medical necessity and medical decision making differ in E/M documentation review
- Why history and exam are discussed as part of assessing medical necessity
- How provider assessment and rationale fit into medical decision making
- Why audit review may focus on broader documentation rather than isolated checklist elements
- How general tools and resources may support review of service levels across care settings
Who Should Read This
- Medical coders
- Auditors
- Compliance professionals
- E/M documentation reviewers
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