What is Medical Necessity?

This section was compiled by Frank M. Painter, D.C.
Send all comments or additions to:   Frankp@chiro.org

FROM:   A Chiro.Org Editorial

“Medical Necessity” is the slippery slope, according to the Physician's News Digest

“There are almost as many definitions of medical necessity as there are payors, laws and courts to interpret them. Generally speaking, though, most definitions incorporate the principle of providing services which are "reasonable and necessary" or "appropriate" in light of clinical standards of practice. The lack of objectivity inherent in these terms often leads to widely varying interpretations by physicians and payors, which, in turn, can result in the care provided not meeting the definition.”

Medicare defines "medical necessity" as services or items reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

From an Insurers standpoint, this is why documentation of the patient encounter is so important. The standard note taking format for every patient encounter is the SOAP note.   Medical (and chiropractic) necessity is defined by your own notes.

Let's review what actually defines “reasonable and necessary” in a SOAP Note:

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S stands for subjective complaints.

During the first part of every patient encounter, the doctor uses their interviewing skills to paint a picture. If the patient has complaints in multiple regions, it's best to cover them one region at a time. For example:

Neck:   Right sided neck pain in the C4-C5 region of a 6/10 severity, which radiates into the right trapezius region, increases to 8/10 with R rotation or R lateral bending, decreases with rest. Patient also experiences neck stiffness of a 5/10 severity, making it difficult and uncomfortable to parallel park safely.

Low Back:   Left sided low back pain in the SI region of a 7/10 severity, with referral to the L buttock and L inguinal region. Pain is decreased with ice, and increases with sit-to-stand after long sitting. This pain has forced the patient to discontinue bowling for the last 2 weeks.

NOTE: If you use any form of shorthand in your notes, make sure that each page has a key at the top that translates your notes back into English.

Examples of Chiropractic Shorthand:

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O stands for objective findings.

This is where we document whatever we find. Orthopedic tests that were positive at the beginning of care...are they still positive? Has ROM (range of motion) improved? Palpation findings for vertebral rotations, fixations (listings), muscle knots (spasm), and trigger points (myofascial disorder) should be documented.

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A stands for assessment.

This is where we state what we found (diagnosis). An example could be as simple as:

Cervical subluxation of C5 with related segmental myospasm, cervicalgia (6/10), with attendant myofascial pain of the upper extremity (5/10).

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P stands for plan.

After the first visit we design a Care Plan.

An excellent selection of care plans are available in Robert Mootz, D.C.'s article:
Chiropractic Care Parameters for Common Industrial Low Back Conditions.

They have been saved in Word format, and are available for your use.

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Dr. Mootz gave us permission to reproduce this wonderful article titled:

Maximizing the Effectiveness and Efficiency of Clinical Documentation

In it, he goes into depth about documenting with exam forms and SOAP notes, and also provides a handy Problem List to make it easy to track the progress of each of the patient's original and subsequent subjective complaints.

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Nataliya Schetchikova, PhD also gave us permission to reproduce her article:

Surviving the Scrutiny, which addresses red flagging of claims, and how to avoid it.

We hope you will find this information useful!

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Since 8-17-2009