Thursday, April 04, 2013

The Irony of "Medical Necessity."



In the state of Maryland, regulations require that patients seen in community mental health centers must see a physician every 90 days for a review, unless they are not taking medications, in which case they must see a physician once every 6 months.  It seems reasonable to me to say that a patient with a chronic disorder on medications should be seen 4 times a year to have their status, medications, lab work, health issues, mental status exam, all reviewed and to make sure the medications are still working and indicated and not causing undo side effects.  At the psychiatrist's discretion, patients can be seen more often, and patients who are having a problem are seen sooner.  Every patient has an assigned therapist and it's not unusual for a therapist to schedule someone to come in sooner than the 90 day review if they aren't doing well.  When I see someone, I often start my note with "Here for 90 day review."  It's code to myself that it's a routine visit to assess the continued necessity of the medications, and it's a bit different than if I write "Seen for an emergency -- sister notes was walking naked on the golf course and the patient is complaining of auditory hallucinations."  

So today I received an email informing me that the clinic is auditing charts to be sure the documentation fits with the CPT codes that are billed.  It's a problem, we're told, if the note says that the patient is being seen for a 90 day review.  It implies that the visit is for paperwork, and that there is no medically necessary reason for the visit and I shouldn't do this.

So wait, the law requires that I see the patient every 90 days, but if I write that that's why the patient is here today, that's a problem, because it's legally required but doesn't make the bar for being "medically necessary"?