Medical Necessity Germane & Inherent to Medicine Medical Necessity is assuming even more importance as the crux of medicine with the increased focus upon the healthcare delivery model transitioning from Fee-for-Service to Fee-for-Value. An inherent challenge in decisions of medical necessity is the inherent subjectiveness of determining whether the care provided meets medical necessity. Determinations of medical necessity are fluid, with different requirements for different third-party payers. The concept of medical necessity spans the entire spectrum of healthcare whether Medicare has Local Coverage Determinations, National Coverage Determinations or other third-party payers have policy bul
Optimization of Documentation- Is This the Right Terminology? Optimization of documentation, is this the right terminology to be utilizing in a conversation regarding documentation improvement and how do you define “optimization of documentation?” DRG were introduced in 1982 as a prospective payment system to contain and curtail excessive Medicare costs associated with Medicare beneficiary hospitalizations. The advent of the DRG system served as a primer for DRG Optimization consulting companies that sprung up like dandelions in the spring, popping up everywhere. These organizations utilized techniques of documentation and coding, often manipulating the clinical truth of documentation in the
Does Reimbursement Focused Behavior Drive Process Improvement? A major challenge of current clinical documentation improvement processes is the undivided focus upon reimbursement as the primary outcome, something undisputable with a clear review of present day Key Performance Indicators. The expression and reporting of the clinical truth in the record beginning with the Emergency Room Documentation, transitioning into the H & P and continuing with the consultant reports and progress notes culminating in the discharge summary is paramount to effective communication of patient care. Often the CDI profession references and points to the fact CDI helps tells the patient story, thereby impacting
Accurate and Complete Documentation Best Aligning and Integrating with the Revenue Cycle To best align and integrate with the revenue cycle with lasting sustainable impact, clinical documentation improvement programs must embrace and operationalize processes that achieve real measurable improvement in documentation. Rather than focus upon present Key Performance Indicators measuring outcomes consisting of gross patient revenue, high performing CDI programs achieve accurate, precise and complete documentation that effectively communicates the patient care provided and the attained outcomes. CDI programs better and more closely align and integrate with the revenue cycle when the established go
