You are responsible for auditing patient records to ensure that documentation justifies medical necessity of those procedures, services, or supplies that have been reported and coded on insurance claims. For each record, you locate patient diagnoses and verify the ICD-10-CM codes reported on claims. You also review documentation in the patient record to ensure that each diagnosis justifies the medical necessity of diagnostic or therapeutic procedures performed and services or supplies provided to patients.
The worksheet that you use to audit patient records includes the following items, which must be documented by the provider:
Patient history, including review of systems
Physical examination, including impression
Diagnostic test results, including analysis of findings
Diagnoses, including duration and comorbidities that impact care
Patient’s treatment, prognosis, and follow-up care
You also review Durable Medical Equipment Prosthetics Orthotics and Supplies (DMEPOS) cases to locate appropriate reports, verify that such reports have been authenticated by the physician, and review for documentation of rehabilitation care and/or medical equipment necessary for patient recuperation. Today, you have also been tasked with verifying durable medical equipment (DME) certificates of medical necessity.
What is a DME certificate of medical necessity, and when is it required?