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PS-101
Medically Necessary vs. Clinically Appropriate Care

Understanding the difference between these two types of care is often the difference between reimbursement or a denial. Learn the difference and how to properly document them.

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This lesson focuses on clearly defining the differences between Medically Necessary care and Clinically Appropriate care, as well as the requirements of each from a documentation perspective.

  • Compare the definition of medically necessary care to clinically appropriate care and explain how they differ
  • Recognize Medicare documentation requirements and apply them when documenting medical necessity
  • Write and implement Policies and Standard Operating Procedures that clarify the intent of and provide the specific definitions to be used for documenting medically necessary care, when appropriate, based on the patient’s clinical presentation

Medically Necessary vs. Clinically Appropriate Care Implementation Guide

Fact Sheet:

  • Medical Necessity Tool Kit

Rapid Tutorial:

  • Medically Necessary Care – Incident, Burst or Full Episode

Sample Policy:

  • Medical Necessity
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