Medical Necessity in Documentation & New Prolonged E/M Coding Updates 2025
Learn how proper documentation will not only help with medical necessity, but also compliance concerns. Coding staff will understand the correct way to query, while providers will learn the importance of accurate documentation. In healthcare documentation, medical necessity justifies the use of specific services or interventions, ensuring that they are consistent with the patient’s clinical needs, supported by evidence, and aligned with accepted clinical practice.
A well-documented statement of medical necessity includes:
Clear Diagnosis: The condition being treated or investigated must be clearly identified and documented.
Reason for Treatment: A detailed explanation of why the treatment, test, or service is required, including how it directly addresses the patient’s clinical situation.
Evidence-based Justification: References to current clinical guidelines, studies, or recognized protocols that support the treatment plan.
Expected Outcome: Documentation of the anticipated benefits or goals of the treatment in relation to the patient's health improvement or condition stabilization.
This documentation is crucial for insurance purposes, ensuring that the services provided are eligible for reimbursement, and for compliance with regulatory and ethical standards.
Learning Objectives
Define Medical Necessity
How Documentation Affects Code Assignment
Discuss Difference Between Medical Necessity and Medical Decision Making (MDM)
How Medical Necessity Affects Diagnosis Coding
Medical necessity and HCC Capture via M.E.A.T.
Challenges to Obtain Proper Documentation for Medical Necessity
Real Chart Examples to Demonstrate Importance of Medical Necessity
Areas Covered in the Session
2021/2023 E/M Guidelines
Diagnosis Documentation
HCC Capture via M.E.A.T. Documentation
Comparative Billing Reports (CBR)
Social Drivers of Health (SDoH)
Add on Complexity Code – G2211
E/M with Minor Procedure
Live Q&A Session
Suggested Attendees
Healthcare Providers or Physicians
Administrators
Medical Billers
Claims Coders
Revenue Cycle Managers
Billing Staff and Companies
Physicians and Other Providers
Healthcare Consultants
Compliance Officers
Office Managers
Practice Manager
Chief Financial Officers
In and Out of Network Providers
Medical Billing Companies
Hospitals and Facilities
Insurance Companies
Healthcare Attorneys
HIM Staff
About the Presenter
Susan Rohde, RHIT, CCS-P, CPC, has more than 28 years of experience in health care industry with an emphasis in coding, health information management, medical necessity and documentation. Susan is currently serving on the education committee for NSCHBC. Her other memberships include AHIMA, NDHIMA, AAPC, NSCHBC, HFMA and MGMA. She specializes in reviewing documentation for accurate reimbursement within Evaluation and Management (E/M) and all surgical specialties, including Interventional Radiology, Anesthesia, Neurosurgical, and Orthopedics, for both ICD-10-CM and CPT codes. Susan helps navigate the ever-changing coding and documentation world and can help your organization in maximizing its coding potential via proper documentation, provider and coding staff education, and understanding of guidelines and regulations.
Additional Information
System Requirement:
Internet Speed: Preferably above 1 MBPS
Headset: Any decent headset and microphone which can be used to hear clearly
Live Course Cancellation Policy: If for any reason Skillacquire need to cancel this program, Skillacquire will notify participants by email of the cancellation no less than 24 hours prior to the expected start time.
For more information, you can reach out to the below contact:
Toll-Free No: 1-302-444-0162
Email: care@skillacquire.com