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 integrity (CDI) initiatives to achieve tremendous improvement in the completeness and quality of documentation and communication of patient care in the electronic health record. Today’s…
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 when they should not. This leads to inaccurate coding of levels, or sometimes missing out on the opportunity of stressing each patient’s true clinical conditions,…
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, can erode net patient revenue for inpatient and outpatient services through process design. In reviewing one particular inpatient case with $118,000 in charges denied by…
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 emergency department (CDI in ED Part I; CDI in ED Part II). Today I will focus on how ED documentation supports medical necessity of investigative…
“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 segment on the series, I had taken a position on medical decision-making (MDM) of the evaluation and management (E&M) record being the overarching criteria for…
Why the Highmark decision—since rescinded—was wrong about medical decision-making relative to medical necessity.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 medical necessity, how do they determine what level of history and exam is medically necessary for a particular presenting problem? The answer: subjectively.  What is…
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 go along with critical care.  Many questions come up when reporting critical care services. You would think it would be fairly straightforward since there are only…
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 is medical necessity? To many, it is the belief that a service or procedure is warranted or justified for a patient. Others view it as a…
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 pertains to today’s topic, medical necessity, is “unexplained clinical variation in care.”What I mean by that is the fact that patients with similar clinical features…
Medical necessity is the concept that healthcare services and supplies must be necessary and appropriate for the evaluation and management of a given disease, condition, illness, or injury. The care must be considered reasonable when judged against current medical standards of care. But clinicians know that guidelines are really not…
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