Safeguarding Medical Necessity in Non-face-to-face Exchanges

Anna McGregor CLP, CPC, CPCO, CPMA, CPA-RA, CEMC, CEMA

September 6, 2024

Has there been a moment when auditing an encounter when one wondered if this service was necessary because a reasonable indication for medical services was not identified? Should medical necessity be identified as the appropriateness of a non-face-to-face encounter?

In August 2024, the National Alliance of Medical Auditing Specialists (NAMAS), a leading authority in the field, actively explored the concept of medical necessity. The following article will ponder whether medical necessity is crucial to non-face-to-face encounters and shed light on its importance and role in evaluating them.

As healthcare professionals, the coder’s role in assessing medical necessity is crucial. AAPC states, “Services rendered to patients should be necessary to affect a cure or change in the condition for which the patient is being seen” (AAPC, 2022). This would be one way to define medical necessity: remember the standard definition of “The overarching criterion. . .” for which many can quote in their sleep. Then, there is the personal favorite of medical condition(s) that is/are documented to the highest specificity level and can correlate with either a procedure code or reasonable purpose for an encounter that supports the need for medical attention.

When reviewing face-to-face events, a practical approach to understanding medical necessity can be easily assessed by the documentation in the note that associates the conditions during the encounter, any orders placed with a rationale for those orders, and the management or plan for the patient moving forward. This practical approach equips healthcare professionals to make informed decisions.

What about non-face-to-face encounters? Just as in defining medical necessity, non-face-to-face encounters should be defined as when a provider and patient are not physically present in the same proximity. This can be performed as a synchronous (real-time) encounter or an asynchronous (store and forward) encounter. The standard list of non-face-to-face encounters is as follows:

Virtual Technology
- E-Visits
  - Email
  - Virtual Check-in
- Telemedicine
  - Behavioral Health
  - ESRD Services
  - Evaluation and Management Encounters
- Telephone Encounters include:
  - Chronic Care Management
  - Remote (Patient) Physiologic Management/Monitoring
  - Remote Therapeutic Monitoring
  - Transitional Care Management

Digital Evaluation and Management Services

When considering non-face-to-face encounters (NFTFE), the first objective is to clearly understand the revised documentation guidelines and assess the encounter’s importance. Remember, History of the Present Illness, Review of Systems, and Exam only require relevant or medically necessary specifics; the core of the note is in the encounter’s Medical Decision-Making (MDM). MDM details the complexity and severity of conditions reviewed during the encounter while specifying the risks of proposed treatment options. Managing the three MDM components delivers the rationale for the encounter: medical necessity.

In considering the importance of medical necessity for NFTFEs, it is central to the encounter to evaluate whether the services are congruent with current documentation guidelines and whether they meet the criteria established in the CPT code uniformed language descriptors developed by the CPT Editorial Panel, which the American Medical Association Board of Trustees oversees (Dotson, 2013). An example of the ongoing revision and expansion of the CPT code sets is that in April 2022, the Panel added new codes for remote services, on the success of Remote Patient Monitoring, to include Remote Therapeutic Monitoring and Remote Therapeutic Treatment Monitoring, further incorporating remote services for the musculoskeletal and respiratory systems, followed by behavioral and ophthalmology therapies.

A recent MLN publication identified a list of errors related to unsatisfactory documentation as frequent concerns during Comprehensive Error Rate Testing (CERT) reviews. In reviewing the critical errors, it is clear that medical necessity is at the top of the list to be identified. Here is a summary of the errors applicable to medical necessity:

“No radiographs that support the procedure’s medical necessity”;
“High errors consisted of insufficient documentation, medical necessity, and incorrect coding of E/M services to support medical necessity and accurate billing of those services”; and
“Documentation of the plan or intent to order a CT scan was insufficient to support its medical necessity”

(Center for Medicare & Medicaid Services, 2024)

How vital is medical necessity for NFTFEs? Starting January 1, 2023, CMS ended its requirement for using Certificates of Medical Necessity and the Durable Medical Equipment Information Forms. This decision supported the documentation reduction efforts developed with the Documentation Guidelines 2021 and the revised Guidelines 2023. Contradicting that move, CMS states that medical necessity in the Social Security Act “will be supported by evidence of medical necessity and quality in such form and fashion and at such time as may reasonably be required by a reviewing quality improvement organization in the exercise of its duties and responsibilities. (2012)”.

What about the adage, “If it is not documented, it never happened?” Is this an old wives’ tale to ensure proper documentation practices or to bring credibility to qualified medical providers’ documentation? Stephanie Allard questions the importance of documentation in her May 26, 2023 article If a Procedure Was Not Documented, Was It Performed? (Allard, 2023). Again, when addressing the importance of medical necessity, is there a clear justification one way or another?

Circling back to whether medical necessity is a crucial component for non-face-to-face encounters, in defining medical necessity, reviewing documentation, understanding non-face-to-face encounters, and discussing a few cautionary references from CMS, it is safe to say that medical necessity is a requirement for billable encounters, regardless if the encounter is face-to-face or non-face-to-face. Moving forward and looking at the past changes to reimbursable healthcare, it is possible to think that medical necessity will not have to be stated for every encounter. Predicting the future is not always a wise move. So, to answer the question, should medical necessity be identified as the appropriateness of a non-face-to-face encounter? The answer is yes; there should be no debate on this topic if the end goal is to receive reimbursement for services rendered.

To be continued . . .

Works Cited

AAPC. (2022). Chapter 1: Introduction. In K. Abel, N. E. Benjamin, L. A. Israel, R. Jain, L. Meaney, J. Piaskowski, . . . P. Zubritzky, Coding for Medical Necessity Reference Guide (p. 1). Salt Lake City: AAPC.

Allard, S. (2023, May 26). If a Procedure Was Not Documented, Was It Performed? Retrieved from https://namas.co/if-a-procedure-was-not-documented-was-it-performed/

Center for Medicare & Medicaid Services. (2024, March). MLN909160, Complying with Medical Record Documentation Requirements. Medical Learning Network. U.S. Department of Health & Human Services (HHS).

Dotson, P. (2013, December). CPT® Codes: What Are They, Why Are They Necessary, and How Are They Developed? Advances in Wound Care, pp. 583–587.

OBLIGATIONS OF HEALTH CARE PRACTITIONERS AND PROVIDERS OF HEALTH CARE SERVICES; SANCTIONS AND PENALTIES; HEARINGS AND REVIEW. (2012, January 1). Retrieved from Social Security Administration: https://www.ssa.gov/OP_Home/ssact/title11/1156.htm

Robeznieks, A. (2022, April 15). As remote patient monitoring expands, so does CPT to describe it. Retrieved from American Medical Association: https://www.ama-assn.org/practice-management/cpt/remote-patient-monitoring-expands-so-does-cpt-describe-it

About Ms. McGregor:

Anna M. McGregor, Managing Director at TTUHSC, Lubbock, is a seasoned medical professional. Her skill set includes auditing, clinical documentation, coding practices, compliance, development and fundraising, grants management, and medical education.