Streamlining Your Charting Process for Prior Authorization Requests

As primary care providers, we've all experienced the frustration of prior authorizations (PAs) disrupting our workflow. Whether it's for medications, tests, or treatments, PAs often feel like a barrier between your clinical judgment and the care your patient needs. However, by tailoring your documentation during the patient visit, you can save time and reduce the likelihood of denials later. Here’s how to optimize your charting process when you anticipate a PA might be required.

Start with a Clear Chief Complaint and History of Present Illness (HPI)

Pay attention to how you frame the patient’s concerns. Insurance companies rely heavily on your documentation to justify medical necessity.

What to include:

• Duration, severity, and progression of symptoms.

• Any prior interventions or treatments attempted (including over-the-counter medications).

• Impact on the patient’s daily activities or quality of life.

Example: Instead of documenting “chronic knee pain,” specify:

“Patient reports 12 months of chronic right knee pain, worsened over the past 3 months, unrelieved by OTC ibuprofen and physical therapy. Pain limits ability to work as a cashier and sleep comfortably.”

Use the Proper Diagnosis Codes

Accurate coding is critical. Include all relevant diagnoses—primary and secondary—to support your case. Avoid unspecified codes unless absolutely necessary, as these are more likely to trigger PA requirements or denials.

Pro Tip: Keep a quick reference guide of commonly used ICD-10 codes handy to streamline this step. 

Justify Medical Necessity in Your Assessment and Plan

The assessment and plan section is where you connect the dots between the diagnosis and your proposed intervention. Highlight why the treatment is essential and why alternative options are not appropriate.

What to include:

• Explicit reasoning for your recommendation.

• A summary of previous treatments and their outcomes.

• Relevant guidelines or evidence-based practices supporting your decision.

Example: Instead of writing:

 “Start patient on biologic therapy,” document:

“Patient has failed methotrexate, sulfasalazine, and NSAIDs for rheumatoid arthritis. Initiating biologic therapy per ACR guidelines to reduce disease activity and prevent joint damage.”

Document Any Patient-Specific Factors

Personalize your note to show why the treatment is uniquely necessary for this patient.

Include:

• Comorbid conditions that make alternative treatments inappropriate.

• Allergies, contraindications, or side effects from prior therapies.

• Social or occupational factors that influence your decision.

Example:

“Due to patient’s history of peptic ulcer disease, NSAIDs are contraindicated, and corticosteroids have resulted in significant weight gain and mood instability.”

Anticipate and Address Potential PA Criteria

Insurance companies often look for specific criteria before approving a PA. While these requirements vary, you can prepare by documenting:

• Failure of first-line or lower-cost treatments.

• Adherence to prior therapies.

• Results of diagnostic tests that support your treatment plan.

• Relevant clinical guidelines.

Example:

“Patient completed 6 weeks of supervised physical therapy for chronic back pain without improvement. MRI demonstrates disc herniation compressing L5-S1 nerve root, supporting need for epidural steroid injection.”

Attach Supporting Documentation

Even if your EMR doesn't require it upfront, having everything ready can save time when the PA request is submitted.

Examples:

• Relevant lab results or imaging reports.

• Notes from prior consultations or specialists.

• Patient-reported outcome measures (e.g., pain scores, functional assessments). 

Use Smart Phrases and Templates

If you often encounter the same PA scenarios, build EMR templates or smart phrases to standardize and speed up your documentation process.

Example Smart Phrase:

.PANEED = “Patient has failed [list prior treatments]. Per [guideline], initiating [treatment] due to [specific factors]. Relevant diagnostics: [insert labs/imaging].”

Conclusion

By anticipating the need for a PA and documenting your notes strategically, you can reduce delays, streamline the approval process, and spend less time battling denials. It’s not just about getting the authorization—it’s about advocating for your patient and ensuring they receive timely care.

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