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Medical Necessity Germane to CDI

January 24, 2018





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 bulletins covering specific services. Medical necessity is materially fundamental to medicine, integral to the revenue cycle and greatly impacts the financial welfare of the patient. A common theme of medical necessity is clinical documentation, to what extent does the provider’s documentation convincingly outline the need for care ordered and/or provided. While there are other requirements associated with establishment of medical necessity such as frequency limitations particular to a service such as screening colonoscopies and screening mammograms, solid clinical documentation serves as the hallmark and drives determination of medical necessity.


Importance of Clinical Documentation


Clinical documentation improve