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Course Description


Coders are taught very strict guidance and rules of code selection look-up, proper order of selection, and linking codes correctly, but the art of abstracting medical necessity from the documentation is often-times not taught until one reaches the world of auditing. This creates problems in that coders typically assign the codes prior to claim submission which may mean that medical necessity is not evaluated. During this session, we will explore this difference and how to ensure that medical necessity can be extrapolated through all areas of coding and auditing.

In this sessoion, Our experts speaker Shannon DeConda, CPC, CPC-I, CEMC, CEMA, CPMA, CRTT will define medical necessity, outline the fundamentals along with the myths and misconceptions of medical necessity, and provide attendees with take away steps of how to ensure proper development and implementation of these concepts within their own team.

Areas Covered In The Session:

  • Define the roles and duties of the coder according to noted resources
  • Define the roles and duties of the auditor according to noted resources
  • Define medical necessity – (1)What is the role of medical necessity? (2) How can a non-clinician auditor validate the clinician? (3) Myths and misconceptions associated with medical necessity.
  • The fundamentals of medical necessity for coders – (1) Why is this necessary? (2) Why don’t they know?
  • Transferring medical necessity into the next phases in the ever-changing healthcare horizon

Learning Objectives:

  • Attendees will get the clear understanding of Coding and Auditing, and the roles & duties of Coder and Auditors.
  • Attendees will learn the defitiniton of Medical Necessity , to enable correct and accurate coding.
  • Attendees will be able to understand clear concepts of Medical Necessity, and the common myths and misconception related to it.
  • Attendees will be able to know the reference  and uses of the Program Integrity Manual that will be used to demonstrate these points as well as referencing to the CERT findings associated with problematic medical necessity issues
  • Attendees will get clear ideas about the next-level medical necessity in this dynamic healthcare industry.

Target Audiences:

  • Physicians
  • Billers
  • coders
  • Medical Auditors
  • Practice Managers
  • Compliance Officers

About Our Speaker:

Shannon DeConda, CPC, CPC-I, CEMC, CEMA, CPMA, CRTT, has been in the healthcare industry for over 20 years with experience from working in a physician practice, to providing healthcare as a respiratory therapist, to working as a biller & coder, to now providing medical audit investigations and educating others in this process.

Ms. DeConda founded NAMAS, the National Alliance of Medical Auditing Specialist, 8 years ago while working as a senior auditor for its parent organization DoctorsManagement. At the time, there were no national certification organizations validating the medical auditor so she founded NAMAS and established the CPMA (Certified Professional Medical Auditor) certification and began a grassroots effort to education and certify professionals (through a partnership arrangement the credential is now offered through another certifying body).

NAMAS is committed to training medical auditors and investigators, but we are also committed to the continued education of those auditors and investigators in the industry by ensuring that myths and legends about the rules and guidelines are separated from the facts. The pursuit that Ms. DeConda is focused on for NAMAS is standardization of processes and efforts with investigations and audits as well as working to provide full and comprehensive interpretations of guidelines and policies in an otherwise ambiguous and ever changing industry.


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