JustCoding’s Guide to Medical Necessity Denials (Pack of 5)

Coders and billers from all settings—physician practice employees, outpatient and inpatient hospital staff, and others—will find JustCoding’s Guide to Medical Necessity Denials, by Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, to be invaluable as they seek to master coding concepts related to medical necessity denials and report compliant codes for the services their facility’s physicians provide.

This handbook 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

Published: June 2022

Page count: 74
ISBN: 978-1-64535-197-9

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 contractors
• Commercial payers

Chapter 2: Supporting Medical Necessity through Documentation

• Objectives
• Coding accuracy and specificity
• Compliance with CPT and ICD-10-PCS
• ICD-10-CM coding guidelines and updates
• Clinical documentation integrity team, collaboration, and clinical indicators
• Compliant billing
• Inpatient and outpatient hospitals
• Professional and physician office outpatient coding
• The query process for medical necessity and compliance
• Modifiers and unbundling concerns with compliance

Chapter 3: Coding and Quality Metrics

• Inpatient acute care hospitals
• Hospital inpatient quality reporting program
• Agency for healthcare research and quality patient safety indicators
• Present on admission
• Outpatient hospitals
• Outpatient quality reporting
• Ambulatory surgical center quality data codes
• Critical care criteria and clinical documentation integrity for critical care
• Physician clinic/office
• Merit-based Incentive Payment System
• Medicare Access and CHIP Reauthorization Act of 2015

Chapter 4: Tackling Medical Necessity Denials

• Leveling up documentation
• Reviewing the appeals process
• Appeal letters
• Letters of medical necessity
• External level of appeal options
• Sample letter of medical necessity

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.