10 Documentation and Coding Principles to Demonstrate Medical Necessity

When preparing medical documentation and coding medical conditions, keep these 10 principles in mind to demonstrate medical necessity for services reported:

  1. List the principal diagnosis, condition, problem, or other reason for the medical service or procedure.
  2. Be specific when describing the patient’s condition, illness, or disease.
  3. Distinguish between acute and chronic conditions, when appropriate.
  4. Identify the acute condition of an emergency situation (e.g., coma, hemorrhage, etc.).
  5. Identify chronic complaints, or secondary diagnoses, only when treatment is provided or when they affect the overall management of the patient’s care.
  6. Identify how injuries occur.
  7. Assign diagnosis codes to the highest documented level of specificity.
  8. For office and/or outpatient services, never use a “rule-out” statement (a suspected but not confirmed diagnosis). If a definitive diagnosis is not determined, report symptoms and/or signs, instead.
  9. All facts must be substantiated by the patient’s medical record, and that record must be available for review upon payer request.
  10. When reporting a patient encounter, select codes that best represent the diagnoses addressed during that visit.