Medical Necessity Archives

Nine Elements of an Effective CDI Program

Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FC September 26, 2022

These foundational elements are essential to assure that there is a better way to improve CDI. Clinical Documentation Integrity (CDI) programs continue to evolve over

Medical Necessity versus MDM: There is a Difference

Terry A. Fletcher BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, ACS-CA, SCP-CA, QMGC, QMCRC, QMPM April 14, 2020

Many healthcare professionals use these terms interchangeably. Medical decision-making specifically refers to the complexity of establishing a diagnosis and/or selecting a management option. Medical necessity

Medical Necessity and Denial Management

ICD10monitor July 2, 2019

Quality work reduces the burden of the denial management process. When my children were young, they really enjoyed the movie “The Neverending Story.” It’s about

A CDI Revolution Unfolding

Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FC March 18, 2019

As the provision of healthcare changes, so too must clinical documentation improvement. I have always been convinced of the strong capabilities of current clinical documentation

Chronic Conditions: Code or Not to Code MCCs

Rhonda Buckholtz, CPC, CPMA, CPC-I, CRC, CDEO, CHPSE, COPC, CPEDC, CGSC February 18, 2019

Understanding the correct use of chronic condition codes in the coding process. Coders are often confused regarding when they should code co-morbid chronic conditions and

Clinical Documentation Integrity Programs Eroding Net Patient Revenue

Glenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FC February 12, 2019

CDI professionals can’t mitigate the magnitude of medical necessity denials by third-party payers. Clinical documentation integrity (CDI) programs, combined with the actions of third-party payers,

Supporting Medical Necessity of Investigative Tests

Erica E. Remer, MD, CCDS November 6, 2018

The aim of documentation is to tell the true story. Last year, I wrote a two-part series on clinical documentation integrity, specifically focusing on the

The Controversy Continues: Medical Necessity versus MDM

Terry A. Fletcher BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, ACS-CA, SCP-CA, QMGC, QMCRC, QMPM July 7, 2018

“Medical necessity” is a much-used but often-misunderstood concept. After our recent four-part series on the “Pitfalls of an Audit” and our last Talk Ten Tuesdays

Warning: Medical Necessity isn’t Medical Decision-Making

Betsy Nicoletti February 6, 2018

Why the Highmark decision—since rescinded—was wrong about medical decision-making relative to medical necessity. When payers and coders downcode evaluation and management (E&M) notes based on

Risks Associated with Critical Care Coding

Deborah Grider, CPC, CPC-H, CPC-I, CPC-P, CPMA, CEMC, CCS-P, CDIP, Certified Clinical Documentation Improvement Practitioner January 30, 2018

Questions abound when reporting critical care services. Reporting Adult Critical care can be complicated. It is not only the coding but the rules and that

CDI and Medical Necessity: Closing the Gap Could Prevent Denials

Rhonda Buckholtz, CPC, CPMA, CPC-I, CRC, CDEO, CHPSE, COPC, CPEDC, CGSC January 16, 2018

Medical policies are based off of evidence-based medicine. Without proper documentation, however, most providers struggle to get services or procedures covered for patients. Exactly what

Medical Necessity: Unexplained Clinical Variation in Care

Bill Rifkin MD, FHM, FACP April 25, 2017

I am a physician who writes and edits guidelines designed to assist in determining appropriate utilization of clinical resources. In a nutshell, the issue that

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