Churning & Ping-Ponging: Establishing the medical necessity of an encounter

You may think of churning as something done on a dairy farm – to agitate cream and turn it into butter.  The Center for Medicare and Medicaid Services (CMS), however, describes the practice of scheduling patient visits more often than is medically necessary as churning.  CMS has suggested that the frequency of visits, based on the severity and specificity of the diagnosis codes reported, may be a target for audit.

Another term that CMS has referenced in a recent seminar is ping-ponging.  This is defined as a patient being “ping-ponged” from a PCP to a specialist and back, or “ping-ponged” among a second or third specialist.  Of note, a study from the Archives of Internal Medicine found that the rate of PCP referrals to specialists doubled in the 10-year period between 1999 and 2009.

Of course, some patients have uncontrolled or concurrent conditions which may warrant more frequent follow up than the same condition would for another patient.  Likewise, a patient may have a new or worsening issue that requires the evaluation and management of a specialist.  The key to avoiding the mis-perception of churning or ping-ponging is substantiating the medical necessity in your medical record.

Your documentation should detail the rationale for and relevant findings of any ordered tests, services or consultations; the patient’s progress and response to treatment – or lack thereof – should also be evident.  Your plan should demonstrate your decision-making process and provide the goals of care and whether there is a specific issue or symptom requiring a more close follow-up for this particular patient.  Remember … an auditor does not know your patient like you do!

CMS has stated that the “Medical necessity of a service is the overarching criterion for payment.”  Your record will substantiate the medical necessity for frequent follow-up or specialty consultation when the management options and plan of care are described, along with the status of the patient’s presenting, concurrent and/or chronic conditions. 

Sources:  Medicare Claims Processing Manual (IOM 100-04, Ch 12 Sec 30.6.1); Medicare Benefit Integrity Manual; NGS JK E&M Concepts and Auditing Solutions (Oct 2014)

For additional information, click here to access the CMS Evaluation and Management Services Guide