Medical necessity
This presentation is the property of its rightful owner.
Sponsored Links
1 / 14

Medical Necessity PowerPoint PPT Presentation

  • Uploaded on
  • Presentation posted in: General

Medical Necessity. Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI Manager Accretive Health. Medical Necessity. Medical Necessity Fundamental to Medicine Integral to Revenue Cycle Basis for healthcare delivery transformation R ight care R ight time R ight reason

Download Presentation

Medical Necessity

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript

Medical necessity

Medical Necessity



Accretive Health

Medical necessity1

Medical Necessity

  • Medical Necessity

    • Fundamental to Medicine

    • Integral to Revenue Cycle

    • Basis for healthcare delivery transformation

      • Right care

      • Right time

      • Right reason

      • Right place

      • Right documentation

New pepper target areas

NEW PEPPER Target Areas

Two midnight rule

Two-Midnight Rule

  • “When a patient enters a hospital for a surgical procedure not on the inpatient only list, a diagnostic test, or any other treatment and the physician expects the beneficiary will require medically necessary [emphasis added] hospital services for 2 or more midnights (including inpatient and pre-admission outpatient time), the services are generally appropriate ...”

Two midnight rule1

Two-Midnight Rule

  • “Documentation in the medical record must support a reasonable expectation of the need for the beneficiary to require a medically necessary stay lasting at least two midnights.”

  • The entire medical record may be reviewed to support or refute the reasonableness of the decision,but entries after the point of the admission order are only used in the context of interpreting what the physician knew and expected at the time of admission

Clinical documentation improvement

Clinical Documentation Improvement



Holistic Documentation



Where am I?

Where am I going

Complete and Accurate Medical Record Documentation




  • Principal Diagnosis

  • Secondary Diagnosis

  • Present on Admission

  • Query Process

Medical necessity2

Medical Necessity

  • What is Medically Necessary Care?

    • Care that needs to be provided during a stay at the hospital

    • Medically necessary for diagnosis & treatment (Social Security Act §1862(a)(1)(A))

  • Documentation to establish medical necessity

    • Clinical status of the patient

Medical necessity3

Medical Necessity

  • Not just a “hospital thing”

  • Information used by Medicare is contained within the medical record documentation of history, examination and medical decision-making.

Medical necessity4

Medical Necessity

  • Medical necessity of E/M services is based on the following attributes of the service that affected the physician’s documented work:

    • Number, acuity and severity/duration of problems addressed through history, physical and medical decision-making.

    • The context of the encounter among all other services previously rendered for the same problem.

    • Complexity of documented comorbidities that clearly influenced physician work.

    • Physical scope encompassed by the problems (number of physical systems affected by the problems).

Physician engagement

Physician Engagement

Physician Engagement

Getting physicians’ Attention

Getting physicians’ Involved

Getting physicians’ Committed

Physician engagement1

Physician Engagement

  • An engaged physician is directly proportional to the degree of satisfaction with his/her profession and specific situation

  • Engaging physicians

    • Improving their outlook and viewpoint on documentation

    • Query process

      • “Burden” vs. “Benefit”

Clinical documentation improvement1

Clinical Documentation Improvement

  • Expanded CDI Chart Review

    • Real documentation improvement opportunities

    • Severity of illness congruent with intensity of service

      • H & P-context of admission

      • Progress notes

      • Discharge summary

    • Documentation mutually beneficial

    • Services that are reasonable and necessary

Cert resource

CERT Resource

  • Documentation Improvement Opportunities abound

  • Read the report of findings WPS Medicare CERT Error Summary-1st QT 2014



  • Identify your facility opportunities

Thank you questions

Thank you. Questions?

  • Login