The Complete Guide to Medical Necessity: JustCoding’s Training and Education Toolkit - eBook

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The Complete Guide to Medical Necessity: JustCoding’s Training and Education Toolkit - eBook

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The Complete Guide to Medical Necessity:
JustCoding’s Training and Education Toolkit - eBook

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, AHIMA-approved ICD-10-CM/PCS trainer

Procedures, and the reasons for performing them, are the core of establishing medical necessity. While coders are responsible for reporting procedures with the correct codes, they must coordinate with billers and physicians to ensure documentation includes the proper diagnoses to meet payers’ medical necessity requirements. Reporting a code for a procedure that is not deemed medically necessary by payers, including CMS and third-party companies, means that code will not be paid—even if the physician believes the procedure was clinically necessary. 

The Complete Guide to Medical Necessity: JustCoding’s Training and Education Toolkit, by Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, combines a book-length PDF, a full-length webinar, and other essential tools and downloadable information to provide coders with the training they need on properly coding while staying compliant with medical necessity requirements. This combined resource accommodates all styles of learning and provides valuable tools to help ensure ongoing compliance, such as sample forms and queries.

Coders and billers from all settings—physician practice employees, outpatient and inpatient hospital staff, and others—will find this comprehensive resource to be invaluable as they seek to master coding concepts related to medical necessity and report compliant codes for the services their facility’s physicians provide.

This toolkit will help users:

  • Comprehend the basics of medical necessity, including why it’s required and how requirements may change by payer
  • Understand changes to medical necessity requirements as a result of ICD-10, MACRA, and other recent federal regulations
  • Learn how to head off potential coding issues before they arise, helping reduce denials and reimbursement delays
  • Reduce queries by coordinating and identifying improvements in physician documentation
  • Connect medical necessity requirements with quality and other performance measures to improve and expedite reporting


About the Author: 

Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, AHIMA-approved ICD-10-CM/PCS trainer, is a compliance expert, data charge entry analyst, and HIPAA privacy specialist. Over the last 25 years, she has conducted prepayment, postpayment, and audit charge services for medical providers and insurance payers. She has worked closely with contracted third-party insurance payers for successful reimbursement outcomes. She has experience with inpatient and outpatient coding for physician- and hospital-based providers and facilities, in addition to supervising coding and clinical staff.

Webb contributes education-based articles, webinars, and updates for national coding publications, including JustCoding. She runs Lori-Lynne’s Coding Coach Blog and is the coding resource for obgynhospitalist.com. She has presented at national AHIMA and AAPC conferences, IdHIMA (state of Idaho) conferences, and local AAPC chapters. She is an AHIMA ACE mentor and teaches CPT, ICD-10, and HCPCS coding.

Webb’s specialty is women’s services, which includes maternal fetal medicine, OB/GYN office and facility coding, OB/GYN hospitalist labor/trauma services, and OB/GYN oncology, urology, and general surgical coding.


Published: July 21, 2017

Pagecount: 60 (with additional handouts and downloads)
Dimensions: N/A (Electronic-only product)
ISBN: 978-1-68308-570-6

Table of Contents

Chapter 1: Introduction to Medical Necessity

  • What is medical necessity?
    • Defining medical necessity
  • Third-party payers
    • Coverage
    • The federal government and Social Security/Medicare
    • Billing and reimbursement
    • Covered versus non-covered services
    • National coverage determinations
    • Local coverage determinations
    • Medicare administrative contractor
    • Commercial payers


Chapter 2: Supporting Medical Necessity through Documentation

  • Coding accuracy and specificity
    • ICD-10-CM coding guidelines and updates
    • Clinical document improvement team, collaboration and clinical indicators
  • Compliant billing
    • Inpatient hospital
    • Outpatient hospital
    • Professional/physician
    • Modifiers
  • The query process 
  • Dealing with denials


Chapter 3: Coding and Quality Metrics

  • Inpatient acute care hospitals
    • Inpatient quality reporting
    • The agency for healthcare research and quality patient safety indicators
    • Present on admission
  • Outpatient hospital billing
    • Outpatient quality reporting
    • Ambulatory surgical center quality data codes
    • Critical care criteria
  • Physician clinic/office
    • Physician quality reporting system
    • Medicare integrity programs
    • Medicare Access and Chip Reauthorization Act of 2015


Additional Components:

Case studies

Frequently asked questions

Sample billing forms

Medical necessity webinar