Documenting Medical Necessity
Medical necessity is always based on the patient's condition. When documenting medical necessity, identify the skilled service and the reason this skilled service is necessary for the beneficiary in objective terms.
Examples:
"Wound care completed per POC to left great toe. No s/s of infection, but patient remains at risk due to diabetic status."
"Range of motion (ROM) as tolerated to lower extremities. Unsafe to teach caregiver ROM due to displaced fracture."
Demonstrate the medical necessity of skilled observation and assessment by documenting the complexity of the beneficiary's condition and co-morbidities that may affect the outcomes of the condition you are assessing. Generally it is expected documentation will show significant changes in the beneficiary's condition and associated changes in the plan of care.
Examples:
"Lung sounds coarse throughout. Patient finished antibiotic therapy today for pneumonia, and to see pulmonologist tomorrow for follow up due to COPD and emphysema."
"Stasis wounds on LLE continue to show 50% granulation tissue and moderate serous drainage. Instructed patient on need to elevate legs and on exercises related to peripheral vascular disease.
See the Medicare Benefit Policy Manual (CMS Pub. 100-02, Ch. 7)
Updated: 12.16.16
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